Provider Demographics
NPI:1154308831
Name:JACKSON, ROBIN EDMUND (MSW)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:EDMUND
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 HIAWATHA LN
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-2471
Mailing Address - Country:US
Mailing Address - Phone:302-678-2196
Mailing Address - Fax:
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:
Practice Address - City:DOVER AFB
Practice Address - State:DE
Practice Address - Zip Code:19902-5300
Practice Address - Country:US
Practice Address - Phone:302-677-3911
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILSW-1048101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health