Healthcare Provider Details

I. General information

NPI: 1659779551
Provider Name (Legal Business Name): SHARLENE JACKSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 QUENTIN RD
BROOKLYN NY
11234-4244
US

IV. Provider business mailing address

PO BOX 27
BRONX NY
10462-0027
US

V. Phone/Fax

Practice location:
  • Phone: 718-854-8370
  • Fax:
Mailing address:
  • Phone: 917-370-2973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number020969-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: