Provider Demographics
NPI:1518955434
Name:JACKSON, MARKUS K (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARKUS
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E JEFFERSON BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1922
Mailing Address - Country:US
Mailing Address - Phone:574-232-2255
Mailing Address - Fax:574-287-9377
Practice Address - Street 1:105 E JEFFERSON BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1922
Practice Address - Country:US
Practice Address - Phone:574-232-2255
Practice Address - Fax:574-287-9377
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004900A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPVPB106032OtherAMERICAN PSYCH SYSTEMS
IN000000368745OtherANTHEM
IN148470KMedicare ID - Type UnspecifiedMEDICARE