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General NPI Number Information
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NPI Number | 1033779533
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Entity Type | Organization
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Legal Business Name | CHRISTY S. JACKSON, PH.D., LLC
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Dates
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Enumeration Date | 06/17/2019
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Last Update Date | 06/17/2019
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Provider Practice Location Address
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Address Line | 352 MAIN ST
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City | DURHAM
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State | CT
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Zip | 06422-1645
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Country | US
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Telephone | 860-266-6467
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Fax |
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Provider Business Mailing Address
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Address Line | 502 CYPRESS RD
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City | NEWINGTON
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State | CT
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Zip | 06111-5618
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Country | US
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Telephone | 860-301-0053
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHRISTY S JACKSON
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Credential | PH.D.
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Telephone | 860-266-6467
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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