Provider Demographics
NPI:1508898578
Name:JACKSON, NIKOL LEIGH (LSW)
Entity Type:Individual
Prefix:MS
First Name:NIKOL
Middle Name:LEIGH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:MRS
Other - First Name:NIKOL
Other - Middle Name:LEIGH
Other - Last Name:JACKSON-ELLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LSW
Mailing Address - Street 1:200 N 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17046-5040
Mailing Address - Country:US
Mailing Address - Phone:717-273-1710
Mailing Address - Fax:717-273-1416
Practice Address - Street 1:1733 PENN AVENUE
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19609-2054
Practice Address - Country:US
Practice Address - Phone:610-670-9923
Practice Address - Fax:610-670-2587
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW013684L101YP2500X
103K00000X
PASW-013684L104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker