Provider Demographics
NPI:1811185721
Name:JACKSON, DONALD JOHN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:JOHN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 HARMONY HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHEPACHET
Mailing Address - State:RI
Mailing Address - Zip Code:02814-1429
Mailing Address - Country:US
Mailing Address - Phone:401-949-0690
Mailing Address - Fax:401-949-2060
Practice Address - Street 1:63 HARMONY HILL RD
Practice Address - Street 2:
Practice Address - City:CHEPACHET
Practice Address - State:RI
Practice Address - Zip Code:02814-1429
Practice Address - Country:US
Practice Address - Phone:401-949-0690
Practice Address - Fax:401-949-2060
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW005611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical