Provider Demographics
NPI:1326195959
Name:JACKSON, SANDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
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 1:2750 N LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-8408
Mailing Address - Country:US
Mailing Address - Phone:157-485-8904
Mailing Address - Fax:157-485-8904
Practice Address - Street 1:2750 N LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-8408
Practice Address - Country:US
Practice Address - Phone:157-485-8904
Practice Address - Fax:157-485-8904
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000694A1041C0700X
IN35000319A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN169540Medicare ID - Type Unspecified