Individual
DR. MARIANNE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
60 PLAZA ST E APT 1K, BROOKLYN, NY 11238-5033
(718) 857-4610
(718) 857-3160
Mailing address
60 PLAZA ST E APT 1K, BROOKLYN, NY 11238-5033
(718) 857-4610
(718) 857-3160
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
07305-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00953168
—
NY
01
—
11559263
CAQH PROVIDER ID
NY
01
—
145969
VALUE OPTIONS MEMBER ID
NY
01
—
5024687
AETNA PROVIDER PIN
NY
01
—
A123282
VALUE OPTIONS VENDER ID
NY
Enumeration date
05/19/2007
Last updated
07/09/2007
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