Basic Information
| Provider Information | |||||||||
| NPI: | 1184952459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | URSULA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 763 BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061082791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602919754 | ||||||||
| FaxNumber: | 8602919728 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 FORBES ST | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061181716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606225340 | ||||||||
| FaxNumber: | 8606225342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2009 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 006586 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 006586 | 01 | CT | LICENSE | OTHER |