Basic Information
| Provider Information | |||||||||
| NPI: | 1841275336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SONYA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 9TH STREET, ROOM 150 | ||||||||
| Address2: | FISCAL ALLOCATIONS AND ESTIMATES UNIT | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958146414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166519475 | ||||||||
| FaxNumber: | 9166518908 | ||||||||
| Practice Location | |||||||||
| Address1: | 10333 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934225808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054682000 | ||||||||
| FaxNumber: | 8054686011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 07/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A078401 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00A784010 | 05 | CA | MEDICAID |