Healthcare Provider Details

I. General information

NPI: 1760857056
Provider Name (Legal Business Name): LISA JACKSON, PHD & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 ROUTE 9
HALFMOON NY
12065-2470
US

IV. Provider business mailing address

1745 ROUTE 9
HALFMOON NY
12065-2470
US

V. Phone/Fax

Practice location:
  • Phone: 518-371-2210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LISA JACKSON
Title or Position: LICENSED PSYCHOLOGIST
Credential:
Phone: 518-265-5264