Provider Demographics
NPI:1467767319
Name:JACKSON, SANDRA LYDIA (LICSW, LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LYDIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LICSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8406 OWENS WAY
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-5715
Mailing Address - Country:US
Mailing Address - Phone:301-782-4551
Mailing Address - Fax:
Practice Address - Street 1:3102 FLORAL PARK RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-9665
Practice Address - Country:US
Practice Address - Phone:301-292-2778
Practice Address - Fax:301-292-0275
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD099901041C0700X
DCLC3027541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical