Provider Demographics
NPI:1366919037
Name:JACKSON WELLNESS GROUP
Entity type:Organization
Organization Name:JACKSON WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZAINAB
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:NCC, LCPC
Authorized Official - Phone:240-506-1797
Mailing Address - Street 1:1811 METZEROTT RD APT 807
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-5192
Mailing Address - Country:US
Mailing Address - Phone:240-506-1797
Mailing Address - Fax:
Practice Address - Street 1:1811 METZEROTT RD APT 807
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-5192
Practice Address - Country:US
Practice Address - Phone:240-506-1797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========OtherBLUE CROSS BLUE SHIELD (BCBS)
MD=========Medicaid