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NPI Code Detail

MEDICARE: DIANE CATHLEEN JACKSON LCSW

MEDICARE: DIANE CATHLEEN JACKSON 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
11041C0700XClinical Social WorkerC004576NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1136K7OTHERNCBCBS OF NC
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1194765289
Entity Type Code : Individual
Provider Name (Legal Business Name) : DIANE CATHLEEN JACKSON LCSW
Provider Business Mailing Address
First Line : 806 HAY ST
Second Line :
City : FAYETTEVILLE
State : NC
Zip : 28305-5312
Country : US
Telephone Number : 910-822-3333
Fax Number : 910-822-3336
Provider Business Practice Location Address
First Line : 806 HAY ST
Second Line :
City : FAYETTEVILLE
State : NC
Zip : 28305-5312
Country : US
Telephone Number : 910-822-3333
Fax Number : 910-822-3336
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/07/2006
Last Update Date : 09/26/2011

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