Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
Y | 101YM0800X | Mental Health Counselor | ||
N | 101YP2500X | Professional Counselor | ||
N | 102L00000X | Psychologist | ||
N | 103T00000X | Psychologist | ||
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | ||
N | 103TH0100X | Health Service |
NPI | 1053733782 |
---|---|
Provider Name | Marguerite Jackson |
First Address | Philadelphia, PA 19151-2704 |
Second Address | Philadelphia, PA 19151-2704 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/01/2014 |
Last Update Date | 22/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
29692MD048189L | (05) | PA |
30053142 | KEYSTONE FIRST (01) | PA |