Provider Demographics
NPI:1295988442
Name:JACKSON, PEGGY ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:ANN
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 1:610 ASTARIAS CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3200
Mailing Address - Country:US
Mailing Address - Phone:239-482-8581
Mailing Address - Fax:239-482-8581
Practice Address - Street 1:12590 WHITEHALL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4680
Practice Address - Country:US
Practice Address - Phone:239-939-9090
Practice Address - Fax:239-482-8581
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW4841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical