Healthcare Provider Details

I. General information

NPI: 1487933438
Provider Name (Legal Business Name): WILLIAM CHARLES JACKSON PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

19 HASLET ST # 1
BOSTON MA
02131-2933
US

V. Phone/Fax

Practice location:
  • Phone: 857-891-1828
  • Fax:
Mailing address:
  • Phone: 857-891-1828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: