Provider Demographics
NPI:1710404470
Name:COY-JACKSON, JADA
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:COY-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 1:194 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1614
Mailing Address - Country:US
Mailing Address - Phone:857-492-8324
Mailing Address - Fax:
Practice Address - Street 1:638 BENNINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1576
Practice Address - Country:US
Practice Address - Phone:857-256-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician