Healthcare Provider Details

I. General information

NPI: 1235725607
Provider Name (Legal Business Name): ERIC GREGORY JACKLIN CAC, ICADC, MS, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 02/17/2023
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1789 NEW BRITAIN AVE
FARMINGTON CT
06032-3317
US

IV. Provider business mailing address

1789 NEW BRITAIN AVE
FARMINGTON CT
06032-3317
US

V. Phone/Fax

Practice location:
  • Phone: 860-754-3507
  • Fax:
Mailing address:
  • Phone: 860-754-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: