Provider Demographics
NPI:1518301597
Name:JACKSON, BRENT L (LMSW)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:L
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 1:1031 W SANETTA ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5047
Mailing Address - Country:US
Mailing Address - Phone:208-466-7443
Mailing Address - Fax:208-466-5058
Practice Address - Street 1:1031 W SANETTA ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5047
Practice Address - Country:US
Practice Address - Phone:208-466-7443
Practice Address - Fax:208-466-5058
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID31373104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker