Provider Demographics
NPI:1407157407
Name:JACKSON, MARILYN SLEDGE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:SLEDGE
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 1:2325 BRIAR GATE DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2325 BRIAR GATE DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2154
Practice Address - Country:US
Practice Address - Phone:334-215-1048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-06
Last Update Date:2010-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2160C1041C0700X
GACSW0037061041C0700X
UT5411455-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical