Provider Demographics
NPI:1083811012
Name:JACKSON, MOSS ALAN (PHD)
Entity Type:Individual
Prefix:MR
First Name:MOSS
Middle Name:ALAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 COULTER AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003
Mailing Address - Country:US
Mailing Address - Phone:610-642-4873
Mailing Address - Fax:610-642-4886
Practice Address - Street 1:125 COULTER AVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003
Practice Address - Country:US
Practice Address - Phone:610-642-4873
Practice Address - Fax:610-642-4886
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS362103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical