Provider Demographics
NPI:1073683686
Name:JACKSON, WAYNE PAUL (LCSW,PIP,CEAP)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:PAUL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCSW,PIP,CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 E 13TH ST
Mailing Address - Street 2:SUITE 227
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36201-4602
Mailing Address - Country:US
Mailing Address - Phone:256-237-9200
Mailing Address - Fax:256-237-9205
Practice Address - Street 1:7 E 13TH ST
Practice Address - Street 2:SUITE 227
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-4602
Practice Address - Country:US
Practice Address - Phone:256-237-9200
Practice Address - Fax:256-237-9205
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0960C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical