Provider Demographics
NPI:1639812282
Name:JACKSON, JUSTIN ALBERT (CPRS)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ALBERT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 MARKET ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505-1235
Mailing Address - Country:US
Mailing Address - Phone:973-390-7089
Mailing Address - Fax:
Practice Address - Street 1:393 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07501-2815
Practice Address - Country:US
Practice Address - Phone:973-523-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCPRS-50177101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)