Jackson Wall, APCC, AMFT

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

AMFT120524 Issued in CA

Practice address

1450 20TH St
Santa Monica, CA 90404-2906

Phone

(310) 309-6001

NPI assigned

Aug 3, 2020

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Jan 1, 2024 through Jan 1, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• St. Joseph Center

  • Community/Behavioral Health Agency
  • Santa Monica, CA
  • NPI 1043416993
  NPD (past)
• St. Joseph Center

  • Community/Behavioral Health Agency
  • Culver City, CA
  • NPI 1407115918
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1596412800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1597276800000",
    "number": "1518577790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1113",
            "city": "REDONDO BEACH",
            "state": "CA",
            "postal_code": "902780113"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1450 20TH ST",
            "city": "SANTA MONICA",
            "state": "CA",
            "postal_code": "904042906",
            "telephone_number": "310-309-6001"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALL",
        "first_name": "JACKSON",
        "credential": "APCC, AMFT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-08-03",
        "last_updated": "2020-08-13",
        "certification_date": "2020-08-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "CA",
            "license": "AMFT120524",
            "primary": true
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "CA",
            "license": "APCC8154",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Daigh Walker
• Mary Kathleen Walker, PHD
• Rhonda Walker, RADT1
• Shem Walker
• Kassandra Walkowiak, D.C.
• Wendy Wall
• Arla Strassburg Wallace, PH.D.
• Michael J. Wallace, M.D.
• William L Wallace, PHD
• Mark S Wallen, DPM

• Mental Health Counselor in Santa Monica, CA
• Providers in Santa Monica, CA by specialty
• Mental Health Counselor in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.