Provider Demographics
NPI:1235229063
Name:JACKSON, DOREEN J (LMHC)
Entity Type:Individual
Prefix:MS
First Name:DOREEN
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ALMON AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4515
Mailing Address - Country:US
Mailing Address - Phone:508-580-8794
Mailing Address - Fax:508-580-1668
Practice Address - Street 1:40 ALMON AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4515
Practice Address - Country:US
Practice Address - Phone:508-580-8794
Practice Address - Fax:508-580-1668
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3183101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA21189788924 01OtherBEECH ST.
MALM0383OtherBLUE CROSS BLUE SHIELD MA
MA343393OtherMAGELLAN
MA1898035OtherMBHP
MA87149OtherUNITED BEHAVIORAL HEALTH
MA1029820OtherNEIGHBORHOOD HEALTH PLAN
MA1898035Medicaid
MA87149OtherUNITED HEALTHCARE
MA411270OtherHARVARD PILGRIM
MA1898035OtherMASS BEHAVIORAL HEALTH PL