Provider Demographics
NPI:1396081295
Name:JACKSON PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:JACKSON PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:BOTHE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:423-650-1851
Mailing Address - Street 1:127 ELM ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NH
Mailing Address - Zip Code:03584-3107
Mailing Address - Country:US
Mailing Address - Phone:423-650-1851
Mailing Address - Fax:
Practice Address - Street 1:97 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NH
Practice Address - Zip Code:03584-3063
Practice Address - Country:US
Practice Address - Phone:423-650-1851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1268103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty