Provider Demographics
NPI:1467577700
Name:JACKSON, JONATHAN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 RIVERSIDE DRIVE
Mailing Address - Street 2:1R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024
Mailing Address - Country:US
Mailing Address - Phone:212-580-5974
Mailing Address - Fax:516-877-4844
Practice Address - Street 1:140 RIVERSIDE DRIVE
Practice Address - Street 2:1R
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024
Practice Address - Country:US
Practice Address - Phone:212-580-5974
Practice Address - Fax:516-877-4844
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV20471Medicare ID - Type Unspecified