Provider Demographics
NPI:1841448891
Name:JACKSON, ITASHA VERONICA (LMSW)
Entity type:Individual
Prefix:
First Name:ITASHA
Middle Name:VERONICA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 PROVIDENCE FORGE RD
Mailing Address - Street 2:
Mailing Address - City:ROYERSFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19468-2934
Mailing Address - Country:US
Mailing Address - Phone:516-238-6160
Mailing Address - Fax:
Practice Address - Street 1:1400 BLACKHORSE HILL RD
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-2040
Practice Address - Country:US
Practice Address - Phone:484-266-9785
Practice Address - Fax:610-466-2229
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081529-1104100000X
PASW132795104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker