Provider Demographics
NPI:1275625568
Name:JACKSON, EVELYN (LCSW)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MILLER LOOP
Mailing Address - Street 2:FORT BENNING
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31905-6560
Mailing Address - Country:US
Mailing Address - Phone:706-545-1661
Mailing Address - Fax:
Practice Address - Street 1:209 MILLER LOOP
Practice Address - Street 2:FORT BENNING
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31905-6560
Practice Address - Country:US
Practice Address - Phone:706-545-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALCSW171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider