Provider Demographics
NPI:1659012797
Name:JACKSON, ERNEST (CPRS)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
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 1:700 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-4360
Mailing Address - Country:US
Mailing Address - Phone:609-334-4575
Mailing Address - Fax:
Practice Address - Street 1:76 W JIMMIE LEEDS RD STE 402
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9400
Practice Address - Country:US
Practice Address - Phone:609-573-5260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCPRS-50229175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist