Provider Demographics
NPI:1790241339
Name:JACKSON, GABRIELLE (LICSW, LCSW)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 FLEET STREET
Mailing Address - Street 2:STE 116
Mailing Address - City:NATIONAL HARBOR
Mailing Address - State:MD
Mailing Address - Zip Code:20745-1548
Mailing Address - Country:US
Mailing Address - Phone:301-291-5479
Mailing Address - Fax:
Practice Address - Street 1:1629 K ST NW STE 300
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1631
Practice Address - Country:US
Practice Address - Phone:202-929-4286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17526104100000X
VA09040094761041C0700X
DCLC500807381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker