Provider Demographics
NPI:1760941322
Name:JACKSON, TATYANA ANTOINETTE (LMHC)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:ANTOINETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 STERLING PL APT 4B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4696
Mailing Address - Country:US
Mailing Address - Phone:646-322-0025
Mailing Address - Fax:
Practice Address - Street 1:102 PILLING ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-1610
Practice Address - Country:US
Practice Address - Phone:718-602-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY014023-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health