Provider Demographics
NPI:1053733782
Name:JACKSON, MARGUERITE (MED, BCPC)
Entity type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED, BCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7556 WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-2704
Mailing Address - Country:US
Mailing Address - Phone:215-400-1551
Mailing Address - Fax:
Practice Address - Street 1:7556 WOODCREST AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151-2704
Practice Address - Country:US
Practice Address - Phone:215-400-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA29692MD048189LMedicaid
PA30053142OtherKEYSTONE FIRST