Provider Demographics
NPI:1073841185
Name:JACKSON, TONY
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 WALDEN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4965
Mailing Address - Country:US
Mailing Address - Phone:716-895-6700
Mailing Address - Fax:716-896-0318
Practice Address - Street 1:150 MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1016
Practice Address - Country:US
Practice Address - Phone:585-445-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid