Provider Demographics
NPI:1205313947
Name:DORYE JACKSON LLC
Entity type:Organization
Organization Name:DORYE JACKSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:DORYE
Authorized Official - Middle Name:EMORY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-979-3503
Mailing Address - Street 1:458 WIRE MILL RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-4711
Mailing Address - Country:US
Mailing Address - Phone:203-979-3503
Mailing Address - Fax:
Practice Address - Street 1:50 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-2710
Practice Address - Country:US
Practice Address - Phone:203-977-3503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008194261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)