Provider Demographics
NPI:1548603871
Name:JACKSON, CHANBRIA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:CHANBRIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16318 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4919
Mailing Address - Country:US
Mailing Address - Phone:718-206-3440
Mailing Address - Fax:718-206-3608
Practice Address - Street 1:16318 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4919
Practice Address - Country:US
Practice Address - Phone:718-206-3440
Practice Address - Fax:718-206-3608
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088632-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical