Provider Demographics
NPI:1083006399
Name:JACKSON, MONEEFAH (LSW)
Entity Type:Individual
Prefix:MS
First Name:MONEEFAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 E NESQUEHONING ST
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18042-6753
Mailing Address - Country:US
Mailing Address - Phone:610-972-0405
Mailing Address - Fax:610-438-1636
Practice Address - Street 1:328 E NESQUEHONING ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-6753
Practice Address - Country:US
Practice Address - Phone:610-972-0405
Practice Address - Fax:610-438-1636
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW132125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker