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NPI Code Detail

MEDICARE: MR. BRANDON CLARK JACKSON LMSW

MEDICARE: MR. BRANDON CLARK JACKSON LMSW
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
1104100000XSocial Worker101654-1NY

General Provider Information

NPI Number : 1427611151
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRANDON CLARK JACKSON LMSW
Provider Business Mailing Address
First Line : 7901 BROADWAY
Second Line :
City : ELMHURST
State : NY
Zip : 11373-1329
Country : US
Telephone Number : 718-396-4515
Fax Number :
Provider Business Practice Location Address
First Line : 7901 BROADWAY
Second Line :
City : ELMHURST
State : NY
Zip : 11373-1329
Country : US
Telephone Number : 718-396-4515
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/18/2019
Last Update Date : 03/10/2026

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