Provider Demographics
NPI:1720185036
Name:JACKSON, CHARLES E JR (LCSW-C, LICSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:E
Last Name:JACKSON
Suffix:JR
Gender:M
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 1:10 N. GREENE STREEET
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201
Mailing Address - Country:US
Mailing Address - Phone:410-605-7279
Mailing Address - Fax:
Practice Address - Street 1:10 N. GREENE STREEET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:410-605-7279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG10149104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker