Provider Demographics
NPI:1619958402
Name:JACKMAN, CHARMAIN FIONA (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARMAIN
Middle Name:FIONA
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02471-0894
Mailing Address - Country:US
Mailing Address - Phone:617-803-2417
Mailing Address - Fax:
Practice Address - Street 1:124 WATERTOWN ST STE 3A
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2599
Practice Address - Country:US
Practice Address - Phone:617-803-2417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0200X
MA8159103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty