Provider Demographics
NPI:1477171635
Name:JACKSON, BARON JR
Entity Type:Individual
Prefix:MR
First Name:BARON
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 W FREDERICK ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17551-1945
Mailing Address - Country:US
Mailing Address - Phone:215-651-9229
Mailing Address - Fax:
Practice Address - Street 1:84 W FREDERICK ST APT 3
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17551-1945
Practice Address - Country:US
Practice Address - Phone:215-651-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA309450661041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool