Provider Demographics
NPI:1598934846
Name:JACKSON, MARSHA W (LISW)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 COOPER RD STE 303
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5600
Mailing Address - Country:US
Mailing Address - Phone:513-942-1862
Mailing Address - Fax:
Practice Address - Street 1:4500 COOPER RD STE 303
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-5600
Practice Address - Country:US
Practice Address - Phone:513-940-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0009123104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0305497Medicaid