Provider Demographics
NPI:1376954131
Name:TAYLOR, JACKSON
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 CROOKE AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-1681
Mailing Address - Country:US
Mailing Address - Phone:845-568-7234
Mailing Address - Fax:
Practice Address - Street 1:345 E 102ND ST
Practice Address - Street 2:SUITE 215
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-5611
Practice Address - Country:US
Practice Address - Phone:212-241-8462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist