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General NPI Number Information
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NPI Number | 1760857056
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Entity Type | Organization
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Legal Business Name | LISA JACKSON, PHD & ASSOCIATES
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Dates
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Enumeration Date | 12/11/2015
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Last Update Date | 12/11/2015
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Provider Practice Location Address
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Address Line | 1745 ROUTE 9
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City | HALFMOON
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State | NY
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Zip | 12065-2470
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Country | US
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Telephone | 518-371-2210
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Fax |
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Provider Business Mailing Address
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Address Line | 1745 ROUTE 9
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City | HALFMOON
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State | NY
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Zip | 12065-2470
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | LISA JACKSON
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Credential |
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Telephone | 518-265-5264
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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