Provider Demographics
NPI:1518711829
Name:CRYSTAL R JACKSON HEALTHY LIFESTYLE LLC
Entity Type:Organization
Organization Name:CRYSTAL R JACKSON HEALTHY LIFESTYLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL MENTAL HEALTH COUNSEOR
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:215-601-7379
Mailing Address - Street 1:622 WATERVIEW LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-2539
Mailing Address - Country:US
Mailing Address - Phone:215-601-7379
Mailing Address - Fax:
Practice Address - Street 1:622 WATERVIEW LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154-2539
Practice Address - Country:US
Practice Address - Phone:215-601-7379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty