Provider Demographics
NPI:1942590310
Name:JACKSON, DEBORAH ANN (LMFT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:ANN
Other - Last Name:D'ANDREA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:47 TOWN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2315
Mailing Address - Country:US
Mailing Address - Phone:860-892-7042
Mailing Address - Fax:860-823-3060
Practice Address - Street 1:47 TOWN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2315
Practice Address - Country:US
Practice Address - Phone:860-892-7042
Practice Address - Fax:860-823-3060
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001443106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235942Medicaid