Provider Demographics
NPI:1831631092
Name:JACKSON, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N MAIN ST # 1290
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5722
Mailing Address - Country:US
Mailing Address - Phone:401-533-3966
Mailing Address - Fax:
Practice Address - Street 1:252 JAVA ST STE 208
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-5519
Practice Address - Country:US
Practice Address - Phone:401-533-3966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health