Provider Demographics
NPI:1235867516
Name:JACKSON, JACQUELINE (LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 ANGEVINE AVE
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-5619
Mailing Address - Country:US
Mailing Address - Phone:917-843-2986
Mailing Address - Fax:
Practice Address - Street 1:26 ANGEVINE AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-5619
Practice Address - Country:US
Practice Address - Phone:917-843-2986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114178-01101YA0400X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)