Healthcare Provider Details

I. General information

NPI: 1154308831
Provider Name (Legal Business Name): ROBIN EDMUND JACKSON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TUSKEGEE BLVD
DOVER AFB DE
19902-5300
US

IV. Provider business mailing address

339 HIAWATHA LN
DOVER DE
19904-2471
US

V. Phone/Fax

Practice location:
  • Phone: 302-677-3911
  • Fax:
Mailing address:
  • Phone: 302-678-2196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLSW-1048
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: