Provider Demographics
NPI:1497973911
Name:JACKSON, JUDITH TEMPLE (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:TEMPLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:DR
Other - First Name:JUDITH
Other - Middle Name:CAROL
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYCHOLOGIST
Mailing Address - Street 1:125 COULTER AVE
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2410
Mailing Address - Country:US
Mailing Address - Phone:610-642-4873
Mailing Address - Fax:610-642-4886
Practice Address - Street 1:125 COULTER AVE
Practice Address - Street 2:FLOOR 2
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2410
Practice Address - Country:US
Practice Address - Phone:610-642-4873
Practice Address - Fax:610-642-4886
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007219L103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)