Provider Demographics
NPI:1932335114
Name:JACKSON, REBECCA MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MICHELLE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IDMT
Mailing Address - Street 1:673 MDG
Mailing Address - Street 2:5955 ZEAMER AVENUE
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506
Mailing Address - Country:US
Mailing Address - Phone:907-580-5858
Mailing Address - Fax:
Practice Address - Street 1:673 MDG
Practice Address - Street 2:5955 ZEAMER AVENUE
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1247031041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical