MEDICARE: DR ULYSSES JACKSON LICENSED MENTAL HEALTH COUNSELING PLLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1861112336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR ULYSSES JACKSON LICENSED MENTAL HEALTH COUNSELING PLLC

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	:

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	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ULYSSES JACKSON
Credential	:
Telephone Number	:	631-767-9294

Provider Enumeration Date	:	09/02/2022
Last Update Date	:	09/02/2022

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