Provider Demographics
NPI:1760013353
Name:JACKSON, ROBERTA MARIE (LCSW CASAC-II)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW CASAC-II
Other - Prefix:MS
Other - First Name:ROBERTA
Other - Middle Name:MARIE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:105 WEST 125TH ST
Mailing Address - Street 2:FRONT 1 #1042
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4444
Mailing Address - Country:US
Mailing Address - Phone:475-900-6271
Mailing Address - Fax:646-759-4019
Practice Address - Street 1:105 W 125TH ST
Practice Address - Street 2:FRONT 1 #1042
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4444
Practice Address - Country:US
Practice Address - Phone:475-900-6271
Practice Address - Fax:646-759-4019
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35723101YA0400X
NY088300-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)