Provider Demographics
NPI:1316081706
Name:JACKSON, JAVEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAVEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JAVEL
Other - Middle Name:JACKSON
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 374457
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-4457
Mailing Address - Country:US
Mailing Address - Phone:770-630-6843
Mailing Address - Fax:
Practice Address - Street 1:4360 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:SUITE 530
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-1049
Practice Address - Country:US
Practice Address - Phone:770-630-6843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002284101YP2500X
GA002009103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBGPWMedicare PIN