MEDICARE: JESSICA LEE JACKSON LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	004718	NY

General Provider Information

NPI Number	:	1427312826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LEE JACKSON LMHC

Provider Business Mailing Address
First Line	:	1818 NEWKIRK AVE
Second Line	:	#5C
City	:	BROOKLYN
State	:	NY
Zip	:	11226-7359
Country	:	US
Telephone Number	:	312-339-6424
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 NEWKIRK AVE
Second Line	:	#5C
City	:	BROOKLYN
State	:	NY
Zip	:	11226-7359
Country	:	US
Telephone Number	:	312-339-6424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2012
Last Update Date	:	06/29/2012

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