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General NPI Number Information
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NPI Number | 1376491035
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Entity Type | Organization
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Legal Business Name | JACKSON
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Dates
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Enumeration Date | 03/18/2026
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Last Update Date | 03/18/2026
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Provider Practice Location Address
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Address Line | 56 WARREN ST FL 2
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City | ROXBURY
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State | MA
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Zip | 02119-3236
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Country | US
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Telephone | 857-364-1103
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Fax |
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Provider Business Mailing Address
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Address Line | 56 WARREN ST FL 2
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City | ROXBURY
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State | MA
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Zip | 02119-3236
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Country | US
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Telephone | 857-364-1103
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Fax |
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Authorized Official
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Title or Position | FOUNDER-DIRECTOR OF PROGRAM OPERATI
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Name | SHYNNA JACKSON
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Credential |
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Telephone | 857-350-6060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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