Provider Demographics
NPI:1629520770
Name:JACKSON, RICHARD ALLEN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALLEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 W LAUREL ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3902
Practice Address - Country:US
Practice Address - Phone:218-454-3844
Practice Address - Fax:218-454-3844
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN232821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical