Provider Demographics
NPI:1164149076
Name:JACKSON, LAUREN TRACY (LMSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:TRACY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 LASALLE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2311
Mailing Address - Country:US
Mailing Address - Phone:860-916-5106
Mailing Address - Fax:
Practice Address - Street 1:125 LASALLE RD STE 300
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2311
Practice Address - Country:US
Practice Address - Phone:860-916-5106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker