Provider Demographics
NPI:1073571428
Name:JACKSON, ALYSA MICHELE (MSW)
Entity Type:Individual
Prefix:MS
First Name:ALYSA
Middle Name:MICHELE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 DEER ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1481
Mailing Address - Country:US
Mailing Address - Phone:254-833-0663
Mailing Address - Fax:
Practice Address - Street 1:3000 'J' STREET,
Practice Address - Street 2:FEDERAL MEDICAL CENTER, CARSWELL
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76127
Practice Address - Country:US
Practice Address - Phone:817-782-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0756951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical