MEDICARE: JULIE JACKSON MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	34005111A	IN

General Provider Information

NPI Number	:	1063782985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE JACKSON MSW, LCSW

Provider Business Mailing Address
First Line	:	429 E VERMONT ST
Second Line	:	SUITE 205
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-3690
Country	:	US
Telephone Number	:	317-289-1117
Fax Number	:	317-631-5872

Provider Business Practice Location Address
First Line	:	429 E VERMONT ST
Second Line	:	SUITE 205
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-3690
Country	:	US
Telephone Number	:	317-289-1117
Fax Number	:	317-631-5872

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2012
Last Update Date	:	01/09/2012

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