Provider Demographics
NPI:1932488194
Name:JACKSON, MARK MONROE (MSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MONROE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 KONA DR
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77554-8623
Mailing Address - Country:US
Mailing Address - Phone:409-354-1838
Mailing Address - Fax:409-935-9193
Practice Address - Street 1:119 KONA DR
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77554-8623
Practice Address - Country:US
Practice Address - Phone:409-354-1838
Practice Address - Fax:409-935-9193
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52697104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker