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General NPI Number Information
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NPI Number | 1073354304
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Entity Type | Individual
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Provider Name | JUSTICE JACKSON LMSW
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Gender | Female
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Dates
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Enumeration Date | 06/03/2024
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Last Update Date | 06/03/2024
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Provider Practice Location Address
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Address Line | 250 W MAIN ST STE 301
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City | BRANFORD
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State | CT
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Zip | 06405-4032
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Country | US
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Telephone | 860-877-8690
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Fax |
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Provider Business Mailing Address
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Address Line | 228 JOY LN APT 2
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City | NEW BRITAIN
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State | CT
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Zip | 06053-1709
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Country | US
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Telephone | 860-877-8690
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 7820
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License Number State | CT
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