Provider Demographics
NPI:1982341681
Name:JACKSON, SYREETA LEA (LCSW)
Entity type:Individual
Prefix:MS
First Name:SYREETA
Middle Name:LEA
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 1:530 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5762
Mailing Address - Country:US
Mailing Address - Phone:401-595-5788
Mailing Address - Fax:401-595-7662
Practice Address - Street 1:530 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5762
Practice Address - Country:US
Practice Address - Phone:401-274-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
RICSW027761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor