Healthcare Provider Details

I. General information

NPI: 1730395369
Provider Name (Legal Business Name): DEBORAH JACKSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 S MAIN ST
FALL RIVER MA
02721-5375
US

IV. Provider business mailing address

148 ATWOOD AVE # 327
CRANSTON RI
02920-4130
US

V. Phone/Fax

Practice location:
  • Phone: 508-821-7777
  • Fax:
Mailing address:
  • Phone: 401-864-2746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114314
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01978
License Number StateRI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: