Provider Demographics
NPI:1093121477
Name:JACKSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
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 1:15 BRANT AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1564
Mailing Address - Country:US
Mailing Address - Phone:908-922-3309
Mailing Address - Fax:
Practice Address - Street 1:15 BRANT AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1564
Practice Address - Country:US
Practice Address - Phone:908-922-3309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor