Provider Demographics
NPI:1861643389
Name:JACKSON, TRACEY ANN (LBSW)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 CEDAR SPGS S
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-6246
Mailing Address - Country:US
Mailing Address - Phone:864-446-3407
Mailing Address - Fax:
Practice Address - Street 1:1547 PARKWAY STE 100
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4081
Practice Address - Country:US
Practice Address - Phone:864-229-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC3430Medicare PIN