Provider Demographics
NPI:1396022158
Name:JACKSON, TONYETTE M (LSW)
Entity Type:Individual
Prefix:MS
First Name:TONYETTE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-0407
Mailing Address - Country:US
Mailing Address - Phone:201-463-2374
Mailing Address - Fax:
Practice Address - Street 1:249 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-1423
Practice Address - Country:US
Practice Address - Phone:201-798-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05305400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker