PHOENIX JACKSON
NPI 1619349933
Counselor - Mental Health in San Rafael, CA

Q: What is Phoenix Jackson's NPI number?

The NPI number for Phoenix Jackson is 1619349933. It was assigned to this individual provider in the NPPES registry on October 26, 2015.

Q: What is Phoenix Jackson's specialty?

The primary specialty registered for this NPI is Counselor, specializing in Mental Health, with taxonomy code 101YM0800X.

Q: Is Phoenix Jackson enrolled in Medicare?

No. Phoenix Jackson has opted out of Medicare through January 1, 2028. Care is provided under private contracts, and Medicare does not pay for services furnished by providers who have opted out.

Q: When was this NPI record last updated?

The NPPES record for Phoenix Jackson was last updated on October 25, 2016. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 9 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.

Active since October 26, 2015Opted out of Medicare · through Jan 1, 2028

1 SAINT VINCENTS DR, SAN RAFAEL, CA 94903(415) 610-1768 Get Directions Write a Review

NPPES record last updated: October 25, 2016. Verified against the NPPES registry weekly; last sync: August 02, 2026.

Record update history: Oct 25, 2016, Sep 29, 2016, Mar 14, 2016 (3 updates tracked since 2016).

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About Phoenix Jackson NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

PHOENIX JACKSON (NPI 1619349933) is an individual mental health provider in San Rafael, California, licensed in California (91873) and active in the NPI registry since October 2015. She has opted out of Medicare through January 1, 2028.

NPPES Registry Identity

NPI1619349933

Entity TypeIndividualFemale

Primary Taxonomy101YM0800X

Provider Legal NamePHOENIX JACKSON

Location Address1 SAINT VINCENTS DRSan Rafael, CA 94903-1504

Mailing Address1 Saint Vincents DrSan Rafael, CA 94903-1504 · (415) 610-1768

Phone(415) 610-1768

Sole ProprietorYes

Enumeration DateOctober 26, 2015

Last NPPES UpdateOctober 25, 20163 updates tracked since enumeration

✔ NPI 1619349933 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 5

★ Primary SpecialtyCounselor · Mental HealthBehavioral Health & Social Service Providers

Taxonomy Code101YM0800X

License✔ Licensed in CA · 91873

Also ListedCounselorTaxonomy 101Y00000X

Also ListedCounselor · SchoolTaxonomy 101YS0200X

Also ListedMarriage & Family TherapistTaxonomy 106H00000X · License 91873 (CA)

Also ListedStudent in an Organized Health Care Education/Training ProgramTaxonomy 390200000X · License 91873 (CA)

1 SAINT VINCENTS DR, San Rafael, CA 94903

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Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

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Opted out of Medicare

Phoenix Jackson has filed a Medicare opt-out affidavit. Services are provided under private contract between the provider and the patient, and are not billed to or reimbursed by Medicare. The opt-out is on file from January 1, 2024 through January 1, 2028.

Opt-Out Effective DateJanuary 1, 2024

Opt-Out In Effect ThroughJanuary 1, 2028Opt-out affidavits renew automatically every two years unless cancelled

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment– Home Health Agency– Power Mobility DevicesAn opted-out provider can still order and refer for Medicare patients in the categories marked above, even though their own services are not covered.

Other Providers at the Same Location NPPES 20

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

MARTINA BAKEBURA BAKILANA

Marriage & Family Therapist