Provider Demographics
NPI:1093721706
Name:JACKSON, BRIDGETTE (LMFT)
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06011-2828
Mailing Address - Country:US
Mailing Address - Phone:860-585-3906
Mailing Address - Fax:860-585-3907
Practice Address - Street 1:440 N MAIN ST # D
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4990
Practice Address - Country:US
Practice Address - Phone:860-314-2052
Practice Address - Fax:860-314-2054
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001126106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004262812Medicaid