Provider Demographics
NPI:1740807411
Name:JACKSON, KEANU MALIQ (LCSW)
Entity Type:Individual
Prefix:
First Name:KEANU
Middle Name:MALIQ
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 BERGEN ST APT 112
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-7455
Mailing Address - Country:US
Mailing Address - Phone:772-834-8567
Mailing Address - Fax:
Practice Address - Street 1:1217 BEDFORD AVE # 206
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-1801
Practice Address - Country:US
Practice Address - Phone:772-834-8567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096448104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker