Healthcare Provider Details

I. General information

NPI: 1497673644
Provider Name (Legal Business Name): TAVON JACKSON LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 MADISON AVE STE 202
BALTIMORE MD
21201-2113
US

IV. Provider business mailing address

940 MADISON AVE STE 202
BALTIMORE MD
21201-2113
US

V. Phone/Fax

Practice location:
  • Phone: 410-777-8710
  • Fax: 410-559-5855
Mailing address:
  • Phone: 410-777-8710
  • Fax: 410-559-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26638
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: