Provider Demographics
NPI:1003516295
Name:JACKSON, JASMINE KIARA
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:KIARA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-5526
Mailing Address - Country:US
Mailing Address - Phone:917-751-5197
Mailing Address - Fax:
Practice Address - Street 1:59 AUDUBON RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-5526
Practice Address - Country:US
Practice Address - Phone:917-751-5197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health