Provider Demographics
NPI:1518241025
Name:JACKSON, GERI LYNNE (LMFT)
Entity Type:Individual
Prefix:
First Name:GERI
Middle Name:LYNNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 HERALD PL
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-5002
Mailing Address - Country:US
Mailing Address - Phone:315-472-7363
Mailing Address - Fax:315-701-2368
Practice Address - Street 1:220 HERALD PL
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-5002
Practice Address - Country:US
Practice Address - Phone:315-472-7363
Practice Address - Fax:315-701-2368
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000689106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA1047OtherGRP MEDICARE
1235184235OtherGROUP NPI
NY02994838OtherGRP MEDICAID