Provider Demographics
NPI:1548753965
Name:JACKSON, JEFFREY (LGSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 CORPORATE CENTRE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-7410
Mailing Address - Country:US
Mailing Address - Phone:843-232-2441
Mailing Address - Fax:
Practice Address - Street 1:2024 CORPORATE CENTRE DR STE 103
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7410
Practice Address - Country:US
Practice Address - Phone:843-232-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3475G104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker