Healthcare Provider Details

I. General information

NPI: 1073571428
Provider Name (Legal Business Name): ALYSA MICHELE JACKSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 'J' STREET, FEDERAL MEDICAL CENTER, CARSWELL
FORT WORTH TX
76127
US

IV. Provider business mailing address

5425 DEER ISLAND DR
FORT WORTH TX
76179-1481
US

V. Phone/Fax

Practice location:
  • Phone: 817-782-4002
  • Fax:
Mailing address:
  • Phone: 254-833-0663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075695
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: