Provider Demographics
NPI:1184047698
Name:JACKSON, ERIC D (PHD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 E BROADWAY APT B
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-6128
Mailing Address - Country:US
Mailing Address - Phone:203-701-9666
Mailing Address - Fax:
Practice Address - Street 1:35 OLD TAVERN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3450
Practice Address - Country:US
Practice Address - Phone:203-701-9666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003329103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical