Provider Demographics
NPI:1801674866
Name:JACKSON, SIDNEY JAMES JR (LSWA)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:JAMES
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:LSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 SEA TOWER DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-1654
Mailing Address - Country:US
Mailing Address - Phone:339-832-6367
Mailing Address - Fax:
Practice Address - Street 1:165 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2988
Practice Address - Country:US
Practice Address - Phone:508-897-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALSWA416877104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker