Provider Demographics
NPI:1982584371
Name:JACKSON, REBECCA ANN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 TECUMSEH WAY
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-2870
Mailing Address - Country:US
Mailing Address - Phone:443-752-3119
Mailing Address - Fax:
Practice Address - Street 1:428 E 25TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5304
Practice Address - Country:US
Practice Address - Phone:410-617-0142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLG14687101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health