Healthcare Provider Details

I. General information

NPI: 1982414660
Provider Name (Legal Business Name): AYANNA JACKSON MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 MCILVAIN ST
CHESTER PA
19013-6234
US

IV. Provider business mailing address

711 MCILVAIN ST
CHESTER PA
19013-6234
US

V. Phone/Fax

Practice location:
  • Phone: 215-490-3546
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0012891
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09932812
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW027076
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: