Provider Demographics
NPI:1184275166
Name:JACKSON, KIM ELAINE (LICSW)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:ELAINE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:1253 C ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2202
Mailing Address - Country:US
Mailing Address - Phone:206-549-4668
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:4909 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-2920
Practice Address - Country:US
Practice Address - Phone:206-549-4668
Practice Address - Fax:206-568-7043
Is Sole Proprietor?:No
Enumeration Date:2019-09-22
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500824061041C0700X
WALW613268711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2229463Medicaid
WA2229463Medicaid