Provider Demographics
NPI:1356603054
Name:JACKSON, CLIFFORD (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 ARABIAN DR
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27205-1802
Mailing Address - Country:US
Mailing Address - Phone:336-626-7901
Mailing Address - Fax:
Practice Address - Street 1:1199 ARABIAN DR
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27205-1802
Practice Address - Country:US
Practice Address - Phone:336-626-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-09
Last Update Date:2012-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0077451041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist