Provider Demographics
NPI:1437768256
Name:JACKSON, REBECCA GRACE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:GRACE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LCSW
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 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1509 DOCTORS CIR BLDG C
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7403
Practice Address - Country:US
Practice Address - Phone:910-662-7500
Practice Address - Fax:910-662-7501
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0136171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical