Provider Demographics
NPI:1336163112
Name:JACKSON, EDITH SINCLAIR (MSW)
Entity Type:Individual
Prefix:MS
First Name:EDITH
Middle Name:SINCLAIR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:EDITH
Other - Middle Name:SINCLAIR
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:VAMC -1 FREEDOM WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6285
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:706-823-3960
Practice Address - Street 1:3465 EVANS TO LOCKS RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-4907
Practice Address - Country:US
Practice Address - Phone:706-863-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0009801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical