Provider Demographics
NPI:1659530053
Name:JACKSON, JERROLD (LMSW)
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE GUSTAVE L LEVY PLACE
Mailing Address - Street 2:BOX 1230 - MOUNT SINAI HOSPITAL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ONE GUSTAVE L LEVY PLACE
Practice Address - Street 2:BOX 1230 - MOUNT SINAI HOSPITAL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP639601041C0700X
NY0772571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical