Provider Demographics
NPI:1245931757
Name:JACKSON, DONNA (MSW, CAC-AD)
Entity type:Individual
Prefix:MISS
First Name:DONNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TENTMILL LN APT L
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6230
Mailing Address - Country:US
Mailing Address - Phone:760-429-0130
Mailing Address - Fax:
Practice Address - Street 1:3310 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4108
Practice Address - Country:US
Practice Address - Phone:667-400-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC1978101YA0400X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)