Provider Demographics
NPI:1689805657
Name:JACKSON, CAROLYN DENISE (LCSW, LCAS-A)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 RANDALL PKWY STE 121
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2567
Mailing Address - Country:US
Mailing Address - Phone:910-520-6083
Mailing Address - Fax:
Practice Address - Street 1:3205 RANDALL PKWY STE 121
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-520-6083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2019-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22913101YA0400X
NCC0112981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)