Provider Demographics
NPI:1821308404
Name:JACKSON, DONNA DANETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:DANETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7534 SELWYN COURT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-2333
Mailing Address - Country:US
Mailing Address - Phone:910-286-3084
Mailing Address - Fax:910-867-3067
Practice Address - Street 1:7534 SELWYN COURT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-2333
Practice Address - Country:US
Practice Address - Phone:910-286-3084
Practice Address - Fax:910-867-3067
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0068711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical