Provider Demographics
NPI:1689431140
Name:JACKSON, NYESHA ALEXIS (LMSW)
Entity Type:Individual
Prefix:MS
First Name:NYESHA
Middle Name:ALEXIS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 RIVER AVE APT 5J
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-2125
Mailing Address - Country:US
Mailing Address - Phone:917-557-6395
Mailing Address - Fax:
Practice Address - Street 1:810 RIVER AVE APT 5J
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-2125
Practice Address - Country:US
Practice Address - Phone:917-557-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122309-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker