Healthcare Provider Details

I. General information

NPI: 1982341681
Provider Name (Legal Business Name): SYREETA LEA JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N MAIN ST
PROVIDENCE RI
02904-5762
US

IV. Provider business mailing address

530 N MAIN ST
PROVIDENCE RI
02904-5762
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-2500
  • Fax:
Mailing address:
  • Phone: 401-595-5788
  • Fax: 401-595-7662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW02776
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: