Provider Demographics
NPI:1750089819
Name:JACKSON, JASMINE LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1417 STONELEIGH PL
Mailing Address - Street 2:
Mailing Address - City:AUBREY
Mailing Address - State:TX
Mailing Address - Zip Code:76227-2707
Mailing Address - Country:US
Mailing Address - Phone:405-819-8903
Mailing Address - Fax:
Practice Address - Street 1:1417 STONELEIGH PL
Practice Address - Street 2:
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227-2707
Practice Address - Country:US
Practice Address - Phone:405-819-8903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107571104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker