Provider Demographics
NPI:1437759594
Name:JACKSON, JESSICA ASHLEY (LSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ASHLEY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25381 STATE ROAD 23
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-9501
Mailing Address - Country:US
Mailing Address - Phone:574-292-1573
Mailing Address - Fax:
Practice Address - Street 1:310 W MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5600
Practice Address - Country:US
Practice Address - Phone:269-262-1815
Practice Address - Fax:269-397-2093
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2023-02-06
Deactivation Date:2022-11-15
Deactivation Code:
Reactivation Date:2023-02-06
Provider Licenses
StateLicense IDTaxonomies
IN99099773A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker