Healthcare Provider Details

I. General information

NPI: 1629109665
Provider Name (Legal Business Name): MARY Y JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8181 PROFESSIONAL PL STE 200
LANDOVER MD
20785-7219
US

IV. Provider business mailing address

16 BURGESS LN
DURHAM NC
27707-2933
US

V. Phone/Fax

Practice location:
  • Phone: 301-306-4590
  • Fax: 301-880-0054
Mailing address:
  • Phone: 919-493-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number21387
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21387
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: