Provider Demographics
NPI:1932567310
Name:JACKSON, PORSHA CAROLYN
Entity Type:Individual
Prefix:
First Name:PORSHA
Middle Name:CAROLYN
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 1:443 BEACH 63RD ST
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1420
Mailing Address - Country:US
Mailing Address - Phone:347-782-9920
Mailing Address - Fax:
Practice Address - Street 1:1847 MOTT AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4201
Practice Address - Country:US
Practice Address - Phone:718-334-6850
Practice Address - Fax:347-246-9670
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health