1326360611 NPI number — JENNIFER J JACKSON MS, LPC

Table of content: JENNIFER J JACKSON MS, LPC (NPI 1326360611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326360611 NPI number — JENNIFER J JACKSON MS, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
JENNIFER
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326360611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 JOHN HANCOCK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN UNIVERSITY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19352-9311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-319-0518
Provider Business Mailing Address Fax Number:
484-667-8047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
364 E. MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-319-0518
Provider Business Practice Location Address Fax Number:
484-667-8047
Provider Enumeration Date:
02/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200188406 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1029057320001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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