Provider Demographics
NPI:1104907187
Name:JACKSON, LAURIE ANN (LCSW R)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16832 127TH AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3156
Mailing Address - Country:US
Mailing Address - Phone:718-525-4864
Mailing Address - Fax:
Practice Address - Street 1:9745 QUEENS BLVD PH FLOOR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2101
Practice Address - Country:US
Practice Address - Phone:718-896-9090
Practice Address - Fax:718-830-0724
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR056949-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP19362Medicare UPIN
NY0072UMMedicare ID - Type UnspecifiedMEDICARE NUMBER