Provider Demographics
NPI:1255769287
Name:JACKSON, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W 28TH ST
Mailing Address - Street 2:4J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-4722
Mailing Address - Country:US
Mailing Address - Phone:917-514-7478
Mailing Address - Fax:
Practice Address - Street 1:330 W 28TH ST
Practice Address - Street 2:4J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4722
Practice Address - Country:US
Practice Address - Phone:917-514-7478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0038997-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health