Provider Demographics
NPI:1700512886
Name:JACKSON, LAURYN WILLIAMS (LMSW)
Entity type:Individual
Prefix:
First Name:LAURYN
Middle Name:WILLIAMS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6812 YELLOWSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3268
Mailing Address - Country:US
Mailing Address - Phone:929-335-0733
Mailing Address - Fax:
Practice Address - Street 1:6812 YELLOWSTONE BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3268
Practice Address - Country:US
Practice Address - Phone:929-335-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116621104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker