Provider Demographics
NPI:1003671512
Name:JACKSON, LAURA (LCSWA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7213 STRAWBERRY FIELDS LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-6897
Mailing Address - Country:US
Mailing Address - Phone:980-949-9250
Mailing Address - Fax:
Practice Address - Street 1:7213 STRAWBERRY FIELDS LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-6897
Practice Address - Country:US
Practice Address - Phone:980-949-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0188761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical