Provider Demographics
NPI:1659779551
Name:JACKSON, SHARLENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHARLENE
Middle Name:
Last Name:JACKSON
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 27
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-0027
Mailing Address - Country:US
Mailing Address - Phone:917-370-2973
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4244
Practice Address - Country:US
Practice Address - Phone:718-854-8370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020969-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical