Provider Demographics
NPI:1245546589
Name:JACKSON, FLORENCE W (LCSW)
Entity type:Individual
Prefix:MRS
First Name:FLORENCE
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 S WASATCH BLVD STE 330B
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-4794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4505 S WASATCH BLVD STE 330B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-4794
Practice Address - Country:US
Practice Address - Phone:801-455-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6224346-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical