Provider Demographics
NPI:1376756098
Name:JACKSON, ANTIMOORE H (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ANTIMOORE
Middle Name:H
Last Name:JACKSON
Suffix:
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 1:14617 SARA DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-5410
Mailing Address - Country:US
Mailing Address - Phone:501-952-5275
Mailing Address - Fax:501-888-3576
Practice Address - Street 1:14617 SARA DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-5410
Practice Address - Country:US
Practice Address - Phone:501-952-5275
Practice Address - Fax:501-888-3576
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1568-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical