Provider Demographics
NPI:1104097948
Name:ELLEN JACKSON, LCSW, LLC
Entity type:Organization
Organization Name:ELLEN JACKSON, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:M R
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-780-9966
Mailing Address - Street 1:3 FUNDY ROAD
Mailing Address - Street 2:SUITE TWO
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1796
Mailing Address - Country:US
Mailing Address - Phone:207-780-9966
Mailing Address - Fax:207-780-9966
Practice Address - Street 1:3 FUNDY ROAD
Practice Address - Street 2:SUITE TWO
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1796
Practice Address - Country:US
Practice Address - Phone:207-780-9966
Practice Address - Fax:207-780-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1392 ME1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty