Healthcare Provider Details

I. General information

NPI: 1003575010
Provider Name (Legal Business Name): JACQUELYN ANGELA JACKSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 W 21ST ST
HUNTINGTON STATION NY
11746-2122
US

IV. Provider business mailing address

3 WINTERBROOKE RD
MOODUS CT
06469-1190
US

V. Phone/Fax

Practice location:
  • Phone: 631-209-7883
  • Fax:
Mailing address:
  • Phone: 631-209-7883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number012735
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: