Provider Demographics
NPI:1891383006
Name:JACKSON, ALISSA NICOLE (LISW-S)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 CORNICE CT
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:OH
Mailing Address - Zip Code:43021-9076
Mailing Address - Country:US
Mailing Address - Phone:614-403-1476
Mailing Address - Fax:
Practice Address - Street 1:929 HARRISON AVE STE 304
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1346
Practice Address - Country:US
Practice Address - Phone:614-940-4868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI09003461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical