Provider Demographics
NPI:1346416955
Name:JACKSON, CLINTON WAYNE JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:WAYNE
Last Name:JACKSON
Suffix:JR
Gender:M
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:MARTIN ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:6600 VAN AALST BOULEVARD
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:762-408-4065
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:762-408-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-03
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
GACSW004875104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker