Provider Demographics
NPI:1942686175
Name:EDWARDS, JACKSON K (DMIN, LCSW)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:K
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DMIN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 SHILOH RD NW STE 3030
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-7186
Mailing Address - Country:US
Mailing Address - Phone:404-334-5859
Mailing Address - Fax:
Practice Address - Street 1:650 HENDERSON DR STE 430
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3760
Practice Address - Country:US
Practice Address - Phone:404-334-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW006645104100000X
GACSW0062351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker