Provider Demographics
NPI:1770638462
Name:WILLIAMS, JACKSON (CASAC - T)
Entity Type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:CASAC - T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-1409
Mailing Address - Country:US
Mailing Address - Phone:212-673-9342
Mailing Address - Fax:
Practice Address - Street 1:2009 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3208
Practice Address - Country:US
Practice Address - Phone:121-234-8466
Practice Address - Fax:212-348-5427
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor