Provider Demographics
NPI:1922511419
Name:JACKSON, ANGELA (LISW-CP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 COLUMBIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2890
Mailing Address - Country:US
Mailing Address - Phone:803-575-0579
Mailing Address - Fax:803-830-3873
Practice Address - Street 1:1180 COLUMBIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2890
Practice Address - Country:US
Practice Address - Phone:803-575-0579
Practice Address - Fax:803-830-3873
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
SC139591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1739Medicaid