Provider Demographics
NPI:1649879743
Name:JACKSON, EDWARD JR (LMFT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 NIAGARA FALLS BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-6494
Mailing Address - Country:US
Mailing Address - Phone:716-201-0522
Mailing Address - Fax:
Practice Address - Street 1:1868 NIAGARA FALLS BLVD STE 103
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-6494
Practice Address - Country:US
Practice Address - Phone:716-201-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001679106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist