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General NPI Number Information
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NPI Number | 1811012669
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Entity Type | Individual
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Provider Name | LISA JACKSON PH.D.
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Gender | Female
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 01/07/2014
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Provider Practice Location Address
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Address Line | 990 ROUTE 146
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City | CLIFTON PARK
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State | NY
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Zip | 12065-3617
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Country | US
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Telephone | 518-581-9525
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Fax |
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Provider Business Mailing Address
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Address Line | 990 ROUTE 146
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City | CLIFTON PARK
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State | NY
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Zip | 12065-3617
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Country | US
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Telephone | 518-265-5264
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 016988
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number | 016988
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License Number State | NY
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