Provider Demographics
NPI:1598104044
Name:JACKSON, JAMES L (MSW,LICDC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW,LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3578 W. BROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-1550
Mailing Address - Country:US
Mailing Address - Phone:614-870-6670
Mailing Address - Fax:
Practice Address - Street 1:1515 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1550
Practice Address - Country:US
Practice Address - Phone:614-294-5677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101193101YA0400X
OH1101526101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH101193OtherLICDC
OH1101526OtherLSW