Active NPI
Jennifer L Jackson, PHD
- Clinical Psychologist
- Summit, NJ
National Provider Identifier
1336360247
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 016536
- Practice address
- 35 Deforest Ave
Summit, NJ 07901-2155 - Phone
- (917) 685-4207
- NPI assigned
- May 1, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 016536 | NY | Primary |
| Clinical Child & Adolescent Psychologist | 103TC2200X | 016536 | NY | |
| Family Psychologist | 103TF0000X | 016536 | NY |
Addresses
Primary practice location
35 Deforest Ave
Summit, NJ 07901-2155
Mailing address
35 Deforest Ave
Summit, NJ 07901-2155
Phone (917) 685-4207
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 4661 | Other | NJ | LICENSE |
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)
- Enrolled
- Credentials
- Doctor of Philosophy
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1177977600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1279152000000",
"number": "1336360247",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "35 DEFOREST AVE",
"city": "SUMMIT",
"state": "NJ",
"postal_code": "079012155",
"telephone_number": "917-685-4207"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "35 DEFOREST AVE",
"city": "SUMMIT",
"state": "NJ",
"postal_code": "079012155",
"telephone_number": "917-685-4207"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "JENNIFER",
"middle_name": "L",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-05-01",
"last_updated": "2010-07-15",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "NY",
"license": "016536",
"primary": true
},
{
"code": "103TC2200X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical Child & Adolescent",
"state": "NY",
"license": "016536",
"primary": false
},
{
"code": "103TF0000X",
"taxonomy_group": "",
"desc": "Psychologist, Family",
"state": "NY",
"license": "016536",
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LICENSE",
"identifier": "4661",
"state": "NJ"
}
],
"endpoints": [],
"other_names": []
}Other providers in Summit, NJ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.