Provider Demographics
NPI:1164457172
Name:JACKSON, JEFFREY S
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 MOORE BUILDING
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:16802
Mailing Address - Country:US
Mailing Address - Phone:814-865-2191
Mailing Address - Fax:814-863-1331
Practice Address - Street 1:314 MOORE BUILDING
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:PA
Practice Address - Zip Code:16802
Practice Address - Country:US
Practice Address - Phone:814-865-2191
Practice Address - Fax:814-863-1331
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005143L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical