Provider Demographics
NPI:1427228485
Name:JACKSON, WAYNYELL (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:WAYNYELL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7205 RUTHERFORD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2711
Mailing Address - Country:US
Mailing Address - Phone:443-429-4880
Mailing Address - Fax:
Practice Address - Street 1:7130 RUTHERFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2701
Practice Address - Country:US
Practice Address - Phone:443-429-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD145961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical