Provider Demographics
NPI:1104198522
Name:JACKSON, ILANA (PSYD)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4256
Mailing Address - Country:US
Mailing Address - Phone:908-839-7117
Mailing Address - Fax:
Practice Address - Street 1:1 SUNNY MEADOW CT
Practice Address - Street 2:APT 102
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-1255
Practice Address - Country:US
Practice Address - Phone:908-839-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05059103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical