Provider Demographics
NPI:1841963485
Name:JACKSON, CAITLIN REBECCA (LCSW)
Entity type:Individual
Prefix:MISS
First Name:CAITLIN
Middle Name:REBECCA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MARIGOLD LN
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-4424
Mailing Address - Country:US
Mailing Address - Phone:339-999-6440
Mailing Address - Fax:
Practice Address - Street 1:2B HAROLD ST
Practice Address - Street 2:
Practice Address - City:HARWICH PORT
Practice Address - State:MA
Practice Address - Zip Code:02646-1517
Practice Address - Country:US
Practice Address - Phone:508-418-8504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2206151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA220615Medicaid