Healthcare Provider Details

I. General information

NPI: 1770004939
Provider Name (Legal Business Name): ROSA JACKSON LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 06/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N HOWARD ST STE 300
BALTIMORE MD
21218-5909
US

IV. Provider business mailing address

3805 RIDGEWOOD AVE
BALTIMORE MD
21215-5610
US

V. Phone/Fax

Practice location:
  • Phone: 443-438-6742
  • Fax:
Mailing address:
  • Phone: 443-803-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number22806
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: