Provider Demographics
NPI:1104370527
Name:JACKSON, ANNA MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MACOPIN AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-2001
Mailing Address - Country:US
Mailing Address - Phone:207-281-2037
Mailing Address - Fax:
Practice Address - Street 1:96 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2929
Practice Address - Country:US
Practice Address - Phone:973-868-8729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00294500101YP2500X
NJ37PC00689300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional