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General NPI Number Information
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NPI Number | 1124971213
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Entity Type | Individual
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Provider Name | MENTIE S JACKSON
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Gender | Female
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Dates
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Enumeration Date | 02/18/2026
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Last Update Date | 02/18/2026
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Provider Practice Location Address
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Address Line | 6 LIBERTY SQ STE 428
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City | BOSTON
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State | MA
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Zip | 02109-5800
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Country | US
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Telephone | 857-567-8880
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Fax |
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Provider Business Mailing Address
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Address Line | 106 SUMMER HILL RD
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City | MIDDLETOWN
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State | CT
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Zip | 06457-5646
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Country | US
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Telephone | 404-840-7272
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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 | 10861
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License Number State | CT
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