Provider Demographics
NPI:1235790783
Name:JACKSON, DAPHIME (CSC-AD)
Entity Type:Individual
Prefix:
First Name:DAPHIME
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CSC-AD
Other - Prefix:
Other - First Name:DAPHINE
Other - Middle Name:
Other - Last Name:CAMPER-JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSC-AD
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-8901
Mailing Address - Country:US
Mailing Address - Phone:800-867-2395
Mailing Address - Fax:410-443-0842
Practice Address - Street 1:8737 BROOKS DR STE 108
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7474
Practice Address - Country:US
Practice Address - Phone:800-867-2395
Practice Address - Fax:410-443-0842
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)