Healthcare Provider Details

I. General information

NPI: 1063325959
Provider Name (Legal Business Name): JENNIFER JACKSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24727 US-6
TOWANDA PA
18848
US

IV. Provider business mailing address

151 JACKSON RD
ROARING BRANCH PA
17765-9119
US

V. Phone/Fax

Practice location:
  • Phone: 570-265-0100
  • Fax:
Mailing address:
  • Phone: 570-979-8597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW144776
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: