Provider Demographics
NPI:1982236022
Name:JACKSON, JYLIAN ANN (LMSW)
Entity Type:Individual
Prefix:
First Name:JYLIAN
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HARRIMAN DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-2410
Mailing Address - Country:US
Mailing Address - Phone:845-291-2600
Mailing Address - Fax:
Practice Address - Street 1:146 PIKE STREET OUTPATIENT CLINIC
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771
Practice Address - Country:US
Practice Address - Phone:845-858-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107538104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker