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General NPI Number Information
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NPI Number | 1407114150
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Entity Type | Individual
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Provider Name | ELISABETH JACKSON PH.D. LCSW-R
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Gender | Female
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Dates
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Enumeration Date | 05/01/2012
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Last Update Date | 04/16/2015
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Provider Practice Location Address
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Address Line | 1 PIERPONT PLAZA SUITE 12134
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City | BROOKLYN
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State | NY
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Zip | 11246
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Country | US
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Telephone | 866-650-2676
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Fax | 212-591-6091
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Provider Business Mailing Address
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Address Line | 244 FIFTH AVE. STE E249
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City | NEW YORK
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State | NY
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Zip | 10001
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Country | US
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Telephone | 866-650-2676
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Fax | 212-591-6091
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 048800
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License Number State | NY
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