Provider Demographics
NPI:1477306454
Name:JACKSON, ELYSHUA RENEE (LISW)
Entity Type:Individual
Prefix:
First Name:ELYSHUA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3053 E HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-1632
Mailing Address - Country:US
Mailing Address - Phone:614-537-2240
Mailing Address - Fax:
Practice Address - Street 1:1550 OLD HENDERSON RD STE N-271
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3626
Practice Address - Country:US
Practice Address - Phone:614-456-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2405083104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker