Provider Demographics
NPI:1427611151
Name:JACKSON, BRANDON CLARK (LMSW)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:CLARK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E 77TH ST APT 1I
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-8865
Mailing Address - Country:US
Mailing Address - Phone:917-499-8149
Mailing Address - Fax:
Practice Address - Street 1:42-77 65TH PLACE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5054
Practice Address - Country:US
Practice Address - Phone:718-429-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101654-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker