Provider Demographics
NPI:1750833414
Name:JACKSON, ALFRED D (LSW)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18313 HILLER AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1707
Mailing Address - Country:US
Mailing Address - Phone:216-778-9390
Mailing Address - Fax:
Practice Address - Street 1:6200 ROCKSIDE WOODS BLVD N STE 305
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2343
Practice Address - Country:US
Practice Address - Phone:216-778-9390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0022623104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker