Provider Demographics
NPI:1841978871
Name:JACKSON, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 BEACH CHANNEL DR FL 1
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1918
Mailing Address - Country:US
Mailing Address - Phone:718-930-1435
Mailing Address - Fax:718-277-2099
Practice Address - Street 1:334 MILFORD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-3704
Practice Address - Country:US
Practice Address - Phone:718-277-2003
Practice Address - Fax:718-277-2099
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician