Provider Demographics
NPI:1033444708
Name:JACKSON, NICOLE C (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 WINN WAY FL 4
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1707
Mailing Address - Country:US
Mailing Address - Phone:404-294-3745
Mailing Address - Fax:
Practice Address - Street 1:8750 MOUNTAIN BLVD
Practice Address - Street 2:BUILDING 69
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-4500
Practice Address - Country:US
Practice Address - Phone:510-777-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA775551041C0700X
GACSW0065671041C0700X
CA61462104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker