Provider Demographics
NPI:1720245194
Name:JACKSON, DANA JAMAL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:JAMAL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:DANA
Other - Middle Name:JAMAL
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:7510 91ST AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-2824
Mailing Address - Country:US
Mailing Address - Phone:847-977-0609
Mailing Address - Fax:718-927-9398
Practice Address - Street 1:7510 91ST AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2824
Practice Address - Country:US
Practice Address - Phone:718-298-2671
Practice Address - Fax:718-296-4660
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016903103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical