=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821440637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JULIE HEIM JACKSON, PHD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2016
-----------------------------------------------------
Last Update Date | 07/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 LITTLETON RD STE 8
-----------------------------------------------------
City | WESTFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01886-3120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-538-6856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 BIGELOW DR
-----------------------------------------------------
City | SUDBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01776-3216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-538-6856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/ OWNER
-----------------------------------------------------
Name | JULIE HEIM JACKSON
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 617-538-6856
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 9213
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 9213
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------