Provider Demographics
NPI:1407344518
Name:RECORD-JACKSON, CHRISTIAN NICOLE (PSY 0810008030)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:NICOLE
Last Name:RECORD-JACKSON
Suffix:
Gender:F
Credentials:PSY 0810008030
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 26TH ST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE BEACH
Mailing Address - State:MD
Mailing Address - Zip Code:20732-9383
Mailing Address - Country:US
Mailing Address - Phone:831-239-8364
Mailing Address - Fax:
Practice Address - Street 1:1060 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:240-857-7186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105956101YP2500X
VA0810008030103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional