Provider Demographics
NPI:1376622217
Name:JACKSON, ALICIA CAROL (01/31/05)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:CAROL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:01/31/05
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 24TH ST
Mailing Address - Street 2:APT. 6F
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4470
Mailing Address - Country:US
Mailing Address - Phone:718-706-8097
Mailing Address - Fax:
Practice Address - Street 1:2094 PITKIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-3509
Practice Address - Country:US
Practice Address - Phone:718-240-0602
Practice Address - Fax:718-240-0601
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069227-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical