Provider Demographics
NPI:1528541497
Name:JACKSON, DARLENE R
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CHRISTY PL
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1840
Mailing Address - Country:US
Mailing Address - Phone:508-580-6800
Mailing Address - Fax:508-587-6633
Practice Address - Street 1:50 CHRISTY PL
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1840
Practice Address - Country:US
Practice Address - Phone:508-580-6800
Practice Address - Fax:508-587-6633
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1121891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical