| Doctor Name: | MS. LA TINA MONIQUE JACKSON |
| NPI Number: | 1144395658 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCSW |
| License Number: | LCS 23512 |
| Business Practice Address: | 10605 Balboa Blvd Suite 100 Granada Hills, CA - 913446342 |
| Business Phone Number: | 8188322400 |
| Business Fax Number: | 8188322567 |
| Mailing Address: | 10515 Balboa Blvd Ste 376, GRANADA HILLS |
| State: | CA |
| Postal Code: | 913446397 |
| Phone Number: | 8184883837 |
| Fax Number: | 8183608753 |
| NPI Enumeration Date: | 11/21/2006 |
| NPI Last Update Date: | 02/09/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | LCS 23512 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |