Provider Demographics
NPI:1497521512
Name:JACKSON, ERIKA LYNNE (N/A)
Entity Type:Individual
Prefix:MS
First Name:ERIKA
Middle Name:LYNNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527-3197
Mailing Address - Country:US
Mailing Address - Phone:774-275-9202
Mailing Address - Fax:
Practice Address - Street 1:29 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527-2005
Practice Address - Country:US
Practice Address - Phone:508-581-5225
Practice Address - Fax:508-581-5225
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0000101Y00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor