Basic Information
| Provider Information | |||||||||
| NPI: | 1598161044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | MSW, LCADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1440 RUSSELL RD | ||||||||
| Address2: | |||||||||
| City: | PAOLI | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193011236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106446464 | ||||||||
| FaxNumber: | 6109816078 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 ROUTE 168 | ||||||||
| Address2: | SUITE 404A | ||||||||
| City: | TURNERSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080123210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106446464 | ||||||||
| FaxNumber: | 6109816078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2014 | ||||||||
| LastUpdateDate: | 11/11/2014 | ||||||||
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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 | 101YA0400X | 37LC00194800 | NJ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.