Provider Demographics
NPI:1114507050
Name:JACKSON, CHARISMA (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARISMA
Middle Name:
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 1:1515 ROUTE 22 W STE 1038
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-6509
Mailing Address - Country:US
Mailing Address - Phone:908-731-0886
Mailing Address - Fax:
Practice Address - Street 1:1515 ROUTE 22 W STE 1038
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-6509
Practice Address - Country:US
Practice Address - Phone:908-731-0886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC060778001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical