Provider Demographics
NPI:1821409020
Name:JACKSON, MARIA (LSW)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 NORTH 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-9528
Mailing Address - Country:US
Mailing Address - Phone:717-440-7535
Mailing Address - Fax:
Practice Address - Street 1:1501 N 21ST ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-3308
Practice Address - Country:US
Practice Address - Phone:717-440-7535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-11
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker