Provider Demographics
NPI:1407114150
Name:JACKSON, ELISABETH (PHD LCSW-R)
Entity Type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD LCSW-R
Other - Prefix:DR
Other - First Name:ELISA
Other - Middle Name:
Other - Last Name:ENGLISH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSWR, PHD
Mailing Address - Street 1:244 FIFTH AVE.
Mailing Address - Street 2:STE E249
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:866-650-2676
Mailing Address - Fax:212-591-6091
Practice Address - Street 1:1 PIERPONT PLAZA
Practice Address - Street 2:SUITE 12134
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11246
Practice Address - Country:US
Practice Address - Phone:866-650-2676
Practice Address - Fax:212-591-6091
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0488001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical