Provider Demographics
NPI:1114464898
Name:JACKSON, JENNIFER E (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
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 1:6600 COUNTY ROAD 330
Mailing Address - Street 2:
Mailing Address - City:BERTRAM
Mailing Address - State:TX
Mailing Address - Zip Code:78605-4094
Mailing Address - Country:US
Mailing Address - Phone:714-299-6800
Mailing Address - Fax:
Practice Address - Street 1:6600 COUNTY ROAD 330
Practice Address - Street 2:
Practice Address - City:BERTRAM
Practice Address - State:TX
Practice Address - Zip Code:78605-4094
Practice Address - Country:US
Practice Address - Phone:714-299-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX689091041C0700X
OK54601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical