Provider Demographics
NPI:1689387607
Name:JACKSON, LORI (MSED)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 JERICHO TPKE STE 212
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-2019
Mailing Address - Country:US
Mailing Address - Phone:929-401-1980
Mailing Address - Fax:
Practice Address - Street 1:110 JERICHO TPKE STE 212
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2019
Practice Address - Country:US
Practice Address - Phone:929-401-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health