Provider Demographics
NPI:1184856239
Name:JACKSON, JEANETTE (COUNSELOR)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-1128
Mailing Address - Country:US
Mailing Address - Phone:347-233-9985
Mailing Address - Fax:
Practice Address - Street 1:1300 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1106
Practice Address - Country:US
Practice Address - Phone:718-954-3800
Practice Address - Fax:718-954-3767
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21300101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)