Provider Demographics
NPI:1174035364
Name:JACKSON, CASSANDRA MARY (LSW)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MARY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:MARY
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:410 N PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3010
Mailing Address - Country:US
Mailing Address - Phone:717-560-7917
Mailing Address - Fax:717-560-6452
Practice Address - Street 1:2845 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-2909
Practice Address - Country:US
Practice Address - Phone:717-840-6444
Practice Address - Fax:717-757-2555
Is Sole Proprietor?:No
Enumeration Date:2017-10-29
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW134363104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker