Provider Demographics
NPI:1003126962
Name:JACKSON, EMILY BROCKETT (PHD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:BROCKETT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CARDINAL CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-1785
Mailing Address - Country:US
Mailing Address - Phone:404-429-0419
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT ROAD
Practice Address - Street 2:ATLANTA VA MEDICAL CENTER
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:404-429-0419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003380103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling