=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962263301
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARON HARRIS JACKSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2024
-----------------------------------------------------
Last Update Date | 01/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 ROUTE 34
-----------------------------------------------------
City | MATAWAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07747-2132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 551-208-2924
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 712
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-0712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-350-2366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 37FA00035000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------