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General NPI Number Information
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NPI Number | 1629528849
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Entity Type | Individual
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Provider Name | ANTOINE JACKSON MSW
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Gender | Male
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Dates
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Enumeration Date | 10/12/2016
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Last Update Date | 10/12/2016
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Provider Practice Location Address
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Address Line | 9080 BEALE RD BUILDING 62, 3RD FLOOR
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City | BETHESDA
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State | MD
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Zip | 20889-5633
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Country | US
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Telephone | 301-319-2587
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Fax |
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Provider Business Mailing Address
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Address Line | 9080 BEALE RD BUILDING 62, 3RD FLOOR
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City | BETHESDA
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State | MD
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Zip | 20889-5633
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Country | US
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Telephone | 301-319-2587
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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 | SW133710
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License Number State | PA
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