Provider Demographics
NPI:1285527291
Name:JACKSON, JARRELL
Entity type:Individual
Prefix:
First Name:JARRELL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 RANDOLPH ST APT L2
Mailing Address - Street 2:
Mailing Address - City:ABINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02351-1397
Mailing Address - Country:US
Mailing Address - Phone:857-221-1359
Mailing Address - Fax:
Practice Address - Street 1:121 RANDOLPH ST APT L2
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:MA
Practice Address - Zip Code:02351-1397
Practice Address - Country:US
Practice Address - Phone:857-221-1359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5894101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty