Provider Demographics
NPI:1346906450
Name:JACKSON, WHITLEY V (LMFT)
Entity Type:Individual
Prefix:
First Name:WHITLEY
Middle Name:V
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 NORTH AVE STE 152
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-2601
Mailing Address - Country:US
Mailing Address - Phone:646-543-9735
Mailing Address - Fax:
Practice Address - Street 1:547 NORTH AVE STE 152
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-2601
Practice Address - Country:US
Practice Address - Phone:646-543-9735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001764106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty