MEDICARE: ULYSSES JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	24980	NY

General Provider Information

NPI Number	:	1376962647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ULYSSES JACKSON

Provider Business Mailing Address
First Line	:	89 WASHINGTON AVE
Second Line	:
City	:	DEER PARK
State	:	NY
Zip	:	11729-6917
Country	:	US
Telephone Number	:	631-767-9294
Fax Number	:	631-767-9294

Provider Business Practice Location Address
First Line	:	89 WASHINGTON AVE
Second Line	:
City	:	DEER PARK
State	:	NY
Zip	:	11729-6917
Country	:	US
Telephone Number	:	631-767-9294
Fax Number	:	631-767-9294

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2014
Last Update Date	:	11/10/2025

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