Provider Demographics
NPI:1437357001
Name:JACKSON, PATTIE D (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:PATTIE
Middle Name:D
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:PO BOX 3042
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-3042
Mailing Address - Country:US
Mailing Address - Phone:443-694-5757
Mailing Address - Fax:
Practice Address - Street 1:4705 HARFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-3205
Practice Address - Country:US
Practice Address - Phone:410-444-0779
Practice Address - Fax:410-444-0669
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD131331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical