Provider Demographics
NPI:1245523448
Name:JACKSON, REBEKAH (PSYD)
Entity type:Individual
Prefix:DR
First Name:REBEKAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446A BLAKE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1286
Mailing Address - Country:US
Mailing Address - Phone:203-387-9400
Mailing Address - Fax:888-772-2160
Practice Address - Street 1:446A BLAKE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1286
Practice Address - Country:US
Practice Address - Phone:203-387-9400
Practice Address - Fax:888-772-2160
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT003182103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program