Provider Demographics
NPI:1063832509
Name:JACKSON, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
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 1:18 J BRADEN THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:FORESTDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02644-1555
Mailing Address - Country:US
Mailing Address - Phone:508-681-8257
Mailing Address - Fax:
Practice Address - Street 1:18 J BRADEN THOMPSON RD
Practice Address - Street 2:
Practice Address - City:FORESTDALE
Practice Address - State:MA
Practice Address - Zip Code:02644-1555
Practice Address - Country:US
Practice Address - Phone:508-681-8257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor