Provider Demographics
NPI:1740703560
Name:JACKSON, NADINE YVETTE (CASAC)
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:YVETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W 128TH ST APT 7
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3027
Mailing Address - Country:US
Mailing Address - Phone:646-657-0063
Mailing Address - Fax:
Practice Address - Street 1:1751 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2809
Practice Address - Country:US
Practice Address - Phone:212-991-4994
Practice Address - Fax:212-414-1431
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2-11436101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)