Provider Demographics
NPI:1770237265
Name:JACKSON, ASHLEY (LMSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
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:PO BOX 539
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21903-5039
Mailing Address - Country:US
Mailing Address - Phone:443-466-8727
Mailing Address - Fax:
Practice Address - Street 1:626 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3320
Practice Address - Country:US
Practice Address - Phone:410-620-7161
Practice Address - Fax:410-620-7168
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28170104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker