Provider Demographics
NPI:1922410448
Name:JACKSON, ANTHONY JEROME (MDIV, MA, DMIN)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JEROME
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MDIV, MA, DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 CHELSEA RD
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1056
Mailing Address - Country:US
Mailing Address - Phone:267-625-9433
Mailing Address - Fax:
Practice Address - Street 1:1826 CHELSEA RD
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-1056
Practice Address - Country:US
Practice Address - Phone:267-625-9433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health