Provider Demographics
NPI:1598403404
Name:JACKSON, RICKY CHARLES
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:CHARLES
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-1331
Mailing Address - Country:US
Mailing Address - Phone:609-845-5098
Mailing Address - Fax:
Practice Address - Street 1:770 WOODLANE RD
Practice Address - Street 2:
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3804
Practice Address - Country:US
Practice Address - Phone:609-845-3738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PH0PR17MB5599OtherEMPLOYMENT