Provider Demographics
NPI:1528503794
Name:JACKSON-TERRELL, RHAYVAN (LCSW)
Entity type:Individual
Prefix:
First Name:RHAYVAN
Middle Name:
Last Name:JACKSON-TERRELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 WILLIAMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2502
Mailing Address - Country:US
Mailing Address - Phone:646-820-9374
Mailing Address - Fax:
Practice Address - Street 1:1529 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2502
Practice Address - Country:US
Practice Address - Phone:718-794-8392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098881-1104100000X
NY0910401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker