=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851038160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON PSYCHIATRIC CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2022
-----------------------------------------------------
Last Update Date | 04/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 WALPOLE ST STE 2
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02062-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-958-6036
-----------------------------------------------------
Fax | 617-360-3002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 WALPOLE ST STE 2
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02062-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-958-6036
-----------------------------------------------------
Fax | 617-360-3002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/FOUNDER
-----------------------------------------------------
Name | MS. HANNAH JACKSON
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 607-280-8280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------