Provider Demographics
NPI:1710435953
Name:JACKSON, KELLY (LCSW-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2628
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20604-2628
Mailing Address - Country:US
Mailing Address - Phone:951-977-1388
Mailing Address - Fax:
Practice Address - Street 1:137 NATIONAL PLAZA
Practice Address - Street 2:SUITE 300
Practice Address - City:NATIONAL HARBOR
Practice Address - State:MD
Practice Address - Zip Code:20745
Practice Address - Country:US
Practice Address - Phone:301-395-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG500811231041C0700X
VA09040117021041C0700X
MD205201041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical