Provider Demographics
NPI:1467959759
Name:JACKSON, WINNIE FONG (PSYD)
Entity Type:Individual
Prefix:
First Name:WINNIE
Middle Name:FONG
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:WINNIE
Other - Middle Name:
Other - Last Name:FONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, HSP-P
Mailing Address - Street 1:3113 GOLDEN NUGGET DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-8052
Mailing Address - Country:US
Mailing Address - Phone:510-908-2173
Mailing Address - Fax:
Practice Address - Street 1:2817 ROCK MERRITT AVE STOP A
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-2540
Practice Address - Country:US
Practice Address - Phone:910-907-6825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007677103TC0700X
NC6345103TC0700X
DCPSYA00208101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health