Basic Information
| Provider Information | |||||||||
| NPI: | 1093231284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PATCHOGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117723121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163632001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 104-70 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182756010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 008069 | NY | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.