Provider Demographics
NPI:1497416788
Name:JACKSON, ANTHONY BERNARD (LMSW)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:BERNARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 GREEN OAK PL STE 250
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-2044
Mailing Address - Country:US
Mailing Address - Phone:281-608-1346
Mailing Address - Fax:832-436-1648
Practice Address - Street 1:1521 GREEN OAK PL STE 250
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-2044
Practice Address - Country:US
Practice Address - Phone:281-608-1342
Practice Address - Fax:832-436-1648
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106666104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker