Provider Demographics
NPI:1417679473
Name:JACKSON, COURTNEY (LMSW)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MR
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:JACKSON-TROUPE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:211 COLLINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-1016
Mailing Address - Country:US
Mailing Address - Phone:585-472-6253
Mailing Address - Fax:
Practice Address - Street 1:4115 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-4813
Practice Address - Country:US
Practice Address - Phone:585-324-9273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109152-01104100000X, 1041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical