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General NPI Number Information
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NPI Number | 1427516699
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Entity Type | Individual
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Provider Name | ERICA MACK-JACKSON
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Gender | Female
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Dates
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Enumeration Date | 03/06/2019
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 4954 E 56TH ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46220-5773
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Country | US
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Telephone | 317-500-4266
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Fax |
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Provider Business Mailing Address
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Address Line | 9110 ELECTRIC CT
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-6104
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Country | US
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Telephone | 317-960-2770
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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 |
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 99091162A
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License Number State | IN
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