Provider Demographics
NPI:1184320442
Name:JACKSON, TONYA R (MS, LPC-A)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4828
Mailing Address - Country:US
Mailing Address - Phone:203-435-5444
Mailing Address - Fax:
Practice Address - Street 1:120 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4828
Practice Address - Country:US
Practice Address - Phone:203-435-5444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT7228101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health