Provider Demographics
NPI:1922626191
Name:JACKSON, MARY P (LCSWA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2648 RANDELMAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-5108
Mailing Address - Country:US
Mailing Address - Phone:336-587-8513
Mailing Address - Fax:
Practice Address - Street 1:4035 UNIVERSITY PKWY STE 101
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3275
Practice Address - Country:US
Practice Address - Phone:336-663-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0149301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical