Healthcare Provider Details

I. General information

NPI: 1639728413
Provider Name (Legal Business Name): TIFFANY JACKSON LSCW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CARNEGIE CTR STE 150
PRINCETON NJ
08540-6285
US

IV. Provider business mailing address

300 CARNEGIE CTR STE 150
PRINCETON NJ
08540-6285
US

V. Phone/Fax

Practice location:
  • Phone: 609-831-3979
  • Fax:
Mailing address:
  • Phone: 609-831-3979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05840600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: