Basic Information
| Provider Information | |||||||||
| NPI: | 1508898578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | NIKOL | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON-ELLISON | ||||||||
| OtherFirstName: | NIKOL | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, LSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 N 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170465040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172731710 | ||||||||
| FaxNumber: | 7172731416 | ||||||||
| Practice Location | |||||||||
| Address1: | 1733 PENN AVENUE | ||||||||
| Address2: | |||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196092054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106709923 | ||||||||
| FaxNumber: | 6106702587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 05/07/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | SW013684L | PA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 104100000X | SW-013684L | PA | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.