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General NPI Number Information
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NPI Number | 1467959759
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Entity Type | Individual
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Provider Name | WINNIE FONG JACKSON PSYD
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Gender | Female
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Dates
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Enumeration Date | 04/12/2018
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Last Update Date | 05/15/2025
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Provider Practice Location Address
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Address Line | 2817 ROCK MERRITT AVE
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City | FORT BRAGG
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State | NC
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Zip | 28310-2540
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Country | US
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Telephone | 910-907-6825
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Fax |
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Provider Business Mailing Address
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Address Line | 2817 ROCK MERRITT AVE
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City | FORT BRAGG
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State | NC
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Zip | 28310-5000
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Country | US
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Telephone | 910-907-6825
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810007677
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PSYA00208
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License Number State | DC
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6345
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License Number State | NC
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