Provider Demographics
NPI:1649762766
Name:JACKSON, EMILY ANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CADIZ
Mailing Address - State:OH
Mailing Address - Zip Code:43907-1026
Mailing Address - Country:US
Mailing Address - Phone:740-491-3819
Mailing Address - Fax:
Practice Address - Street 1:500 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:WINTERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-3701
Practice Address - Country:US
Practice Address - Phone:740-491-3819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08016103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical