Provider Demographics
NPI:1477949659
Name:HARRIS-JACKSON, CHANDRA NICOLE (LCSW-C)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:NICOLE
Last Name:HARRIS-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 1:8620 MAYAONE ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-1992
Mailing Address - Country:US
Mailing Address - Phone:410-916-1348
Mailing Address - Fax:
Practice Address - Street 1:8620 MAYAONE ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-1992
Practice Address - Country:US
Practice Address - Phone:410-916-1348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD198451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical