Provider Demographics
NPI:1235531823
Name:JACKSON, ERIC T (LSW)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-2685
Mailing Address - Country:US
Mailing Address - Phone:724-941-4070
Mailing Address - Fax:724-941-5083
Practice Address - Street 1:110 HIDDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-2685
Practice Address - Country:US
Practice Address - Phone:724-941-4070
Practice Address - Fax:724-941-5083
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW131239104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker