Provider Demographics
NPI:1679997837
Name:JACKSON, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 KATHERINE LEE BATES RD # 21
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02540-2845
Mailing Address - Country:US
Mailing Address - Phone:774-454-3290
Mailing Address - Fax:
Practice Address - Street 1:155 KATHERINE LEE BATES RD # 21
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2845
Practice Address - Country:US
Practice Address - Phone:774-454-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-08
Last Update Date:2014-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8102103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical