Provider Demographics
NPI:1821293168
Name:LACKNER, JEFFREY MARK (PSYD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MARK
Last Name:LACKNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-0093
Mailing Address - Country:US
Mailing Address - Phone:716-898-5671
Mailing Address - Fax:716-898-3040
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:ROOM G208
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-5671
Practice Address - Fax:716-898-3040
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012051103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00025302101OtherUNIVERA
NYDF1724OtherRR MEDICARE
NY000523299002OtherBLUE CROSS
NY6108856OtherIHA
NYDF1724OtherRR MEDICARE