Provider Demographics
NPI:1225324189
Name:JACKSON, IRIS (LCSW-C)
Entity Type:Individual
Prefix:DR
First Name:IRIS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 TRIBUTARY ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-6514
Mailing Address - Country:US
Mailing Address - Phone:443-438-9532
Mailing Address - Fax:443-438-9852
Practice Address - Street 1:6610B TRIBUTARY ST STE 310A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-6503
Practice Address - Country:US
Practice Address - Phone:443-438-9532
Practice Address - Fax:443-438-9852
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MD15995104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health