Healthcare Provider Details

I. General information

NPI: 1003516295
Provider Name (Legal Business Name): JASMINE KIARA JACKSON MS.ED., LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ELM ST APT W4
BEVERLY NJ
08010-2530
US

IV. Provider business mailing address

418 BROADWAY # 11756
ALBANY NY
12207-2922
US

V. Phone/Fax

Practice location:
  • Phone: 646-941-3107
  • Fax:
Mailing address:
  • Phone: 518-818-6769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number018368
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: