Provider Demographics
NPI:1720589773
Name:JACKSON, KEIJUANNA JANEE (LMSW)
Entity Type:Individual
Prefix:MISS
First Name:KEIJUANNA
Middle Name:JANEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 CAP ROCK LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-8906
Mailing Address - Country:US
Mailing Address - Phone:219-789-1899
Mailing Address - Fax:
Practice Address - Street 1:2928 W 5TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2242
Practice Address - Country:US
Practice Address - Phone:817-332-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX59218104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker