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General NPI Number Information
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NPI Number | 1437759594
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Entity Type | Individual
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Provider Name | JESSICA ASHLEY JACKSON LSW
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Gender | Female
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Dates
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Enumeration Date | 10/28/2020
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Last Update Date | 02/06/2023
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Provider Practice Location Address
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Address Line | 310 W MCKINLEY AVE
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City | MISHAWAKA
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State | IN
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Zip | 46545-5600
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Country | US
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Telephone | 269-262-1815
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Fax | 269-397-2093
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Provider Business Mailing Address
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Address Line | 25381 STATE ROAD 23
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City | SOUTH BEND
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State | IN
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Zip | 46614-9501
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Country | US
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Telephone | 574-292-1573
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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 | 99099773A
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License Number State | IN
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