Provider Demographics
NPI:1902033350
Name:JACKSON, LISA OLIVIA (LMSW, CASAC)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:OLIVIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 CLAYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-6809
Mailing Address - Country:US
Mailing Address - Phone:631-334-1761
Mailing Address - Fax:
Practice Address - Street 1:1444 5TH AVENUE
Practice Address - Street 2:FAMILY SERVICE LEAGUE
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-647-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9582101YA0400X
NY0767991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)