Provider Demographics
NPI:1912944158
Name:JACKSON, AMBER ADNEY (LCSW)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ADNEY
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 1:528 N COLLEGE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-3401
Mailing Address - Country:US
Mailing Address - Phone:479-856-9956
Mailing Address - Fax:888-455-6401
Practice Address - Street 1:528 N COLLEGE AVE STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-3401
Practice Address - Country:US
Practice Address - Phone:479-856-9956
Practice Address - Fax:888-455-6401
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1934-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y354OtherBLUE SHIELD PROVIDER #
747768OtherBEACON HEALTH