Provider Demographics
NPI:1972990844
Name:JACKSON, MARK A (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5528 CARTAGENA DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3504
Mailing Address - Country:US
Mailing Address - Phone:917-319-1210
Mailing Address - Fax:
Practice Address - Street 1:513 MENENDEZ ST
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2233
Practice Address - Country:US
Practice Address - Phone:917-319-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-18
Last Update Date:2015-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW115081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical