Provider Demographics
NPI:1669921193
Name:JACKSON THERAPY SERVICES LLC
Entity type:Organization
Organization Name:JACKSON THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ILANA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:908-839-7117
Mailing Address - Street 1:1 SUNNY MEADOW CT
Mailing Address - Street 2:APT 102
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-1255
Mailing Address - Country:US
Mailing Address - Phone:908-839-7117
Mailing Address - Fax:
Practice Address - Street 1:405 ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4256
Practice Address - Country:US
Practice Address - Phone:908-839-7117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05059103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty