Provider Demographics
NPI:1942492863
Name:JACKSON, JACQUELINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6178 OXON HILL RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745
Mailing Address - Country:US
Mailing Address - Phone:301-567-4751
Mailing Address - Fax:301-567-3856
Practice Address - Street 1:6178 OXON HILL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745
Practice Address - Country:US
Practice Address - Phone:301-567-4751
Practice Address - Fax:301-567-3856
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02954103TC0700X
DCPSY1741103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
38100003OtherBLUE CROSS BLUE SHIELD