Provider Demographics
NPI:1326360611
Name:JACKSON, JENNIFER J (MS, LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 JOHN HANCOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN UNIVERSITY
Mailing Address - State:PA
Mailing Address - Zip Code:19352-9311
Mailing Address - Country:US
Mailing Address - Phone:302-319-0518
Mailing Address - Fax:484-667-8047
Practice Address - Street 1:364 E. MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711
Practice Address - Country:US
Practice Address - Phone:302-319-0518
Practice Address - Fax:484-667-8047
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-27
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE200188406Medicaid
PA1029057320001Medicaid