Provider Demographics
NPI:1942521539
Name:JACKSON, DOROTHY W (LCSW)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 MYERS CORNERS RD
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-2219
Mailing Address - Country:US
Mailing Address - Phone:203-521-4747
Mailing Address - Fax:845-728-0667
Practice Address - Street 1:1076 MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-3606
Practice Address - Country:US
Practice Address - Phone:203-521-4747
Practice Address - Fax:845-728-0667
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0578321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03308647Medicaid