Provider Demographics
NPI:1336572726
Name:JACKSON, JESSICA L (ATC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:492 NAUGHRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:LONG VALLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07853-3807
Mailing Address - Country:US
Mailing Address - Phone:908-358-5024
Mailing Address - Fax:
Practice Address - Street 1:492 NAUGHRIGHT RD
Practice Address - Street 2:
Practice Address - City:LONG VALLEY
Practice Address - State:NJ
Practice Address - Zip Code:07853-3807
Practice Address - Country:US
Practice Address - Phone:908-358-5024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT00098000174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator