Individual
MR. MATTHEW JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
714 N MICHIGAN ST, SOUTH BEND, IN 46601-1035
(574) 647-7477
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
20042961A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300017159
—
IN
Enumeration date
03/06/2015
Last updated
05/01/2023
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