Provider Demographics
NPI:1639467293
Name:JACKSON-AUSTIN, THELMA PAULETTE (LCSW-C, LICSW)
Entity Type:Individual
Prefix:MS
First Name:THELMA
Middle Name:PAULETTE
Last Name:JACKSON-AUSTIN
Suffix:
Gender:F
Credentials:LCSW-C, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MERCANTILE LN
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5327
Mailing Address - Country:US
Mailing Address - Phone:301-518-7127
Mailing Address - Fax:
Practice Address - Street 1:1300 MERCANTILE LN
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5327
Practice Address - Country:US
Practice Address - Phone:301-518-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD084201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical