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General NPI Number Information
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NPI Number | 1508786591
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Entity Type | Individual
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Provider Name | AVA JACKSON MHC-LP
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Gender | Female
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Dates
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Enumeration Date | 07/20/2026
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Last Update Date | 07/20/2026
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Provider Practice Location Address
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Address Line | 3 PICCADILLY CT
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City | NEWBURGH
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State | NY
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Zip | 12550-2435
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Country | US
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Telephone | 718-772-7623
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Fax |
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Provider Business Mailing Address
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Address Line | 1441 BROADWAY FL 5
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City | NEW YORK
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State | NY
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Zip | 10018-1879
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Country | US
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Telephone | 646-389-0611
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 18-P134324-01
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License Number State | NY
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