Provider Demographics
NPI:1245624535
Name:JACKSON, DEBORAH
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 PILGRIM LN
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-5000
Mailing Address - Country:US
Mailing Address - Phone:484-476-6543
Mailing Address - Fax:
Practice Address - Street 1:401 PILGRIM LN
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-5000
Practice Address - Country:US
Practice Address - Phone:484-476-6543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)