Provider Demographics
NPI:1629546965
Name:JACKSON, TERRI L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 BRANDY DR
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-3794
Mailing Address - Country:US
Mailing Address - Phone:256-688-0800
Mailing Address - Fax:256-688-0860
Practice Address - Street 1:655 BRANDY DR
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-3794
Practice Address - Country:US
Practice Address - Phone:256-688-0800
Practice Address - Fax:256-688-0860
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AL4696C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker