Provider Demographics
NPI:1801299797
Name:JACKSON, HEATHER CAITLIN (LSW)
Entity type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:CAITLIN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLANSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45332-9707
Mailing Address - Country:US
Mailing Address - Phone:937-417-6200
Mailing Address - Fax:937-548-1500
Practice Address - Street 1:212 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1913
Practice Address - Country:US
Practice Address - Phone:937-548-1635
Practice Address - Fax:937-548-1500
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1100675104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker