Provider Demographics
NPI:1326224288
Name:JACKSON, LAURA K (LCSW; LCDC III)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW; LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-1430
Mailing Address - Country:US
Mailing Address - Phone:859-581-8974
Mailing Address - Fax:859-581-9595
Practice Address - Street 1:3629 CHURCH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41015-1430
Practice Address - Country:US
Practice Address - Phone:859-581-8974
Practice Address - Fax:859-581-9595
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLCSW 39521041C0700X
OHLSW-090009331041C0700X
OHLCDC III- 101140101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)