Active NPI
Phoenix Jackson
- Mental Health Counselor
- San Rafael, CA
National Provider Identifier
1619349933
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 91873
- Practice address
- 1 Saint Vincents Dr
San Rafael, CA 94903-1504 - Phone
- (415) 610-1768
- NPI assigned
- Oct 26, 2015
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 5
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Marriage & Family Therapist | 106H00000X | 91873 | CA | |
| Counselor | 101Y00000X | |||
| School Counselor | 101YS0200X | |||
| Student in an Organized Health Care Education/Training Program | 390200000X | 91873 | CA | |
| Mental Health Counselor | 101YM0800X | 91873 | CA | Primary |
Addresses
Primary practice location
1 Saint Vincents Dr
San Rafael, CA 94903-1504
Mailing address
1 Saint Vincents Dr
San Rafael, CA 94903-1504
Phone (415) 610-1768
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
- Opted out of Medicare
- Yes, effective Jan 1, 2024 through Jan 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 110164 | CA | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1445817600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1477353600000",
"number": "1619349933",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1 SAINT VINCENTS DR",
"city": "SAN RAFAEL",
"state": "CA",
"postal_code": "949031504",
"telephone_number": "415-610-1768"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1 SAINT VINCENTS DR",
"city": "SAN RAFAEL",
"state": "CA",
"postal_code": "949031504",
"telephone_number": "415-610-1768"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "PHOENIX",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2015-10-26",
"last_updated": "2016-10-25",
"status": "A"
},
"taxonomies": [
{
"code": "106H00000X",
"taxonomy_group": "",
"desc": "Marriage & Family Therapist",
"state": "CA",
"license": "91873",
"primary": false
},
{
"code": "101Y00000X",
"taxonomy_group": "",
"desc": "Counselor",
"state": null,
"license": null,
"primary": false
},
{
"code": "101YS0200X",
"taxonomy_group": "",
"desc": "Counselor, School",
"state": null,
"license": null,
"primary": false
},
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": "CA",
"license": "91873",
"primary": false
},
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "CA",
"license": "91873",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Rafael, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.