Healthcare Provider Details

I. General information

NPI: 1053733782
Provider Name (Legal Business Name): MARGUERITE JACKSON M.ED, BCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7556 WOODCREST AVE
PHILADELPHIA PA
19151-2704
US

IV. Provider business mailing address

7556 WOODCREST AVE
PHILADELPHIA PA
19151-2704
US

V. Phone/Fax

Practice location:
  • Phone: 215-400-1551
  • Fax:
Mailing address:
  • Phone: 215-400-1551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: