Provider Demographics
NPI:1417037185
Name:JACKSON, GAIL M (MA)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PORTLAND DR
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-4816
Mailing Address - Country:US
Mailing Address - Phone:215-581-5479
Mailing Address - Fax:
Practice Address - Street 1:BELMONT CENTER, 4200 MONUMENT ROAD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131
Practice Address - Country:US
Practice Address - Phone:215-581-5479
Practice Address - Fax:215-581-3827
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC001382101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)