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General NPI Number Information
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NPI Number | 1417679473
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Entity Type | Individual
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Provider Name | COURTNEY JACKSON LMSW
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Gender | Female
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Dates
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Enumeration Date | 09/16/2022
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Last Update Date | 09/16/2022
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Provider Practice Location Address
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Address Line | 4115 LAKE AVE
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City | ROCHESTER
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State | NY
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Zip | 14612-4813
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Country | US
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Telephone | 585-324-9273
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Fax |
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Provider Business Mailing Address
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Address Line | 211 COLLINGWOOD DR
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City | ROCHESTER
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State | NY
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Zip | 14621-1016
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Country | US
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Telephone | 585-472-6253
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 109152-01
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 109152-01
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 1041S0200X
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Taxonomy Name | School Social Worker
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License Number | 109152-01
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License Number State | NY
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