Provider Demographics
NPI:1720578768
Name:JACKSON, TIFFANY (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:CHIVLARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1230
Mailing Address - Country:US
Mailing Address - Phone:812-423-7791
Mailing Address - Fax:
Practice Address - Street 1:320 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-3519
Practice Address - Country:US
Practice Address - Phone:812-385-5275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical