Provider Demographics
NPI:1184832396
Name:JACKSON, MARIANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PLAZA ST E APT 1K
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-5033
Mailing Address - Country:US
Mailing Address - Phone:718-857-4610
Mailing Address - Fax:718-857-3160
Practice Address - Street 1:60 PLAZA ST E APT 1K
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-5033
Practice Address - Country:US
Practice Address - Phone:718-857-4610
Practice Address - Fax:718-857-3160
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07305-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11559263OtherCAQH PROVIDER ID
NY5024687OtherAETNA PROVIDER PIN
NY145969OtherVALUE OPTIONS MEMBER ID
NYA123282OtherVALUE OPTIONS VENDER ID
NY00953168Medicaid
NYV55082Medicare ID - Type UnspecifiedPROVIDER NUMBER