Provider Demographics
NPI:1205017803
Name:JACKSON, NICOLE M (MA, LPC, LCADC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 NORWOOD AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1859
Mailing Address - Country:US
Mailing Address - Phone:732-948-2132
Mailing Address - Fax:
Practice Address - Street 1:232 NORWOOD AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1859
Practice Address - Country:US
Practice Address - Phone:732-948-2132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-25
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00345200101Y00000X, 101YP2500X
NJ37LC00119500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)