1407114150 NPI number — DR. ELISABETH JACKSON PH.D. LCSW-R

Table of content: DR. ELISABETH JACKSON PH.D. LCSW-R (NPI 1407114150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407114150 NPI number — DR. ELISABETH JACKSON PH.D. LCSW-R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
ELISABETH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D. LCSW-R
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ENGLISH
Provider Other First Name:
ELISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSWR, PH.D
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1407114150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
244 FIFTH AVE.
Provider Second Line Business Mailing Address:
STE E249
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-650-2676
Provider Business Mailing Address Fax Number:
212-591-6091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 PIERPONT PLAZA
Provider Second Line Business Practice Location Address:
SUITE 12134
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-650-2676
Provider Business Practice Location Address Fax Number:
212-591-6091
Provider Enumeration Date:
05/01/2012

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: 1041C0700X , with the licence number:  048800 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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