Provider Demographics
NPI:1740320506
Name:JACKSON, JILL J (MSW LICSW)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WENHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01984-1459
Mailing Address - Country:US
Mailing Address - Phone:978-468-1894
Mailing Address - Fax:
Practice Address - Street 1:225 MAIN ST
Practice Address - Street 2:
Practice Address - City:WENHAM
Practice Address - State:MA
Practice Address - Zip Code:01984-1459
Practice Address - Country:US
Practice Address - Phone:978-468-1894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1054031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA71PO3459OtherBCBS PROVIDER #