Healthcare Provider Details

I. General information

NPI: 1285386599
Provider Name (Legal Business Name): ALLAN JAMES JACKSON I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 KINGS HWY
BROOKLYN NY
11229-1209
US

IV. Provider business mailing address

1623 KINGS HWY
BROOKLYN NY
11229-1209
US

V. Phone/Fax

Practice location:
  • Phone: 718-954-3800
  • Fax:
Mailing address:
  • Phone: 718-954-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number0
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: