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General NPI Number Information
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NPI Number | 1962268326
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Entity Type | Individual
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Provider Name | COLIN JACKSON LSW
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Gender | Male
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Dates
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Enumeration Date | 02/23/2024
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Last Update Date | 02/23/2024
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Provider Practice Location Address
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Address Line | 395 S CENTER ST
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City | ORANGE
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State | NJ
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Zip | 07050-3205
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Country | US
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Telephone | 973-323-3909
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Fax |
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Provider Business Mailing Address
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Address Line | 36 MOUNTAIN AVE
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City | MAPLEWOOD
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State | NJ
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Zip | 07040-2542
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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 |
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 44SL06983800
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License Number State | NJ
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