Provider Demographics
NPI:1639667611
Name:JACKSON, SKYLETTE V (MS, CAADC)
Entity Type:Individual
Prefix:
First Name:SKYLETTE
Middle Name:V
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28879 HUDSON CORNER RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MD
Mailing Address - Zip Code:21838-2105
Mailing Address - Country:US
Mailing Address - Phone:443-614-0829
Mailing Address - Fax:
Practice Address - Street 1:28879 HUDSON CORNER RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:MD
Practice Address - Zip Code:21838-2105
Practice Address - Country:US
Practice Address - Phone:443-614-0829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)