Healthcare Provider Details

I. General information

NPI: 1487319208
Provider Name (Legal Business Name): BRENDALAN JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 01/20/2024
Certification Date: 01/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9790 FRANKFURT DR
WALDORF MD
20603-5346
US

IV. Provider business mailing address

9790 FRANKFURT DR
WALDORF MD
20603-5346
US

V. Phone/Fax

Practice location:
  • Phone: 202-459-8733
  • Fax:
Mailing address:
  • Phone: 202-459-8733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberQ3-0000338
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC20002422
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904014977
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: