Active NPI
Eric D Jackson, PHD
- Clinical Psychologist
- Orange, CT
National Provider Identifier
1184047698
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 003329
- Practice address
- 35 Old Tavern Rd
Suite 103
Orange, CT 06477-3450 - Phone
- (203) 701-9666
- NPI assigned
- Feb 4, 2014
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 003329 | CT | Primary |
Addresses
Primary practice location
35 Old Tavern Rd
Suite 103
Orange, CT 06477-3450
Mailing address
88 E Broadway Apt B
Milford, CT 06460-6128
Phone (203) 701-9666
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 003329 | CT | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1391472000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1391472000000",
"number": "1184047698",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "88 E BROADWAY APT B",
"city": "MILFORD",
"state": "CT",
"postal_code": "064606128",
"telephone_number": "203-701-9666"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "35 OLD TAVERN RD",
"address_2": "SUITE 103",
"city": "ORANGE",
"state": "CT",
"postal_code": "064773450",
"telephone_number": "203-701-9666"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "ERIC",
"middle_name": "D",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2014-02-04",
"last_updated": "2014-02-04",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CT",
"license": "003329",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Orange, CT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.