Provider Demographics
NPI:1033779533
Name:CHRISTY S. JACKSON, PH.D., LLC
Entity Type:Organization
Organization Name:CHRISTY S. JACKSON, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:860-266-6467
Mailing Address - Street 1:502 CYPRESS RD
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-5618
Mailing Address - Country:US
Mailing Address - Phone:860-301-0053
Mailing Address - Fax:
Practice Address - Street 1:352 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:CT
Practice Address - Zip Code:06422-1645
Practice Address - Country:US
Practice Address - Phone:860-266-6467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty