Basic Information
| Provider Information | |||||||||
| NPI: | 1932567310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | PORSHA | ||||||||
| MiddleName: | CAROLYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 443 BEACH 63RD ST | ||||||||
| Address2: | |||||||||
| City: | ARVERNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116921420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3477829920 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1847 MOTT AVE | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116914201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183346850 | ||||||||
| FaxNumber: | 3472469670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2016 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.