Provider Demographics
NPI:1841452356
Name:JACKSON, JENNELL A (LCSW)
Entity type:Individual
Prefix:MS
First Name:JENNELL
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 IRON BRIDGE RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-5304
Mailing Address - Country:US
Mailing Address - Phone:732-784-8309
Mailing Address - Fax:732-782-0429
Practice Address - Street 1:501 IRON BRIDGE RD
Practice Address - Street 2:SUITE 15
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-5304
Practice Address - Country:US
Practice Address - Phone:732-784-8309
Practice Address - Fax:732-782-0429
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC054860001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ311452OtherMEDICARE PTAN