Provider Demographics
NPI:1922716711
Name:JACKSON, MARCELLA (LMSW)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8831 SATYR HILL RD STE 107
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-2437
Mailing Address - Country:US
Mailing Address - Phone:443-838-1700
Mailing Address - Fax:
Practice Address - Street 1:8831 SATYR HILL RD STE 107
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-2437
Practice Address - Country:US
Practice Address - Phone:443-838-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18439101YP2500X, 104100000X, 251B00000X, 261QM0801X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD18439OtherLICENSE ID
MD1922716711Medicaid