MEDICARE: MR. JACKSON WILLIAMS C.A.S.A.C. - T

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	101Y00000X	Counselor		NY

General Provider Information

NPI Number	:	1770638462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACKSON WILLIAMS C.A.S.A.C. - T

Provider Business Mailing Address
First Line	:	189 ALLEN ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10002-1409
Country	:	US
Telephone Number	:	212-673-9342
Fax Number	:

Provider Business Practice Location Address
First Line	:	2009 3RD AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10029-3208
Country	:	US
Telephone Number	:	121-234-8466
Fax Number	:	212-348-5427

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

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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