Provider Demographics
NPI:1376968172
Name:JACKSON, TINA (LCSW)
Entity Type:Individual
Prefix:
First Name:TINA
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 1:16351 I94
Mailing Address - Street 2:HOME ON THE RANGE
Mailing Address - City:SENTINEL BUTTE
Mailing Address - State:ND
Mailing Address - Zip Code:58654-9500
Mailing Address - Country:US
Mailing Address - Phone:701-872-3745
Mailing Address - Fax:701-872-3748
Practice Address - Street 1:280 1ST ST BLDG 23
Practice Address - Street 2:
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330-8273
Practice Address - Country:US
Practice Address - Phone:575-572-5676
Practice Address - Fax:575-572-1523
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4950104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker