Provider Demographics
NPI:1427391333
Name:WILLS-JACKSON, CELESTIAL (PHD)
Entity Type:Individual
Prefix:DR
First Name:CELESTIAL
Middle Name:
Last Name:WILLS-JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-6126
Mailing Address - Country:US
Mailing Address - Phone:516-377-1806
Mailing Address - Fax:516-377-1806
Practice Address - Street 1:7000 AUSTIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist