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General NPI Number Information
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NPI Number | 1700186707
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Entity Type | Individual
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Provider Name | MARY SEBRENA JACKSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 10/25/2010
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Last Update Date | 10/25/2010
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Provider Practice Location Address
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Address Line | 450 RACETRACK RD
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City | MCDONOUGH
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State | GA
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Zip | 30252-6837
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Country | US
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Telephone | 770-305-9881
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Fax | 678-565-4626
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Provider Business Mailing Address
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Address Line | PO BOX 123
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City | MCDONOUGH
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State | GA
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Zip | 30253-0123
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Country | US
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Telephone | 770-305-9881
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Fax | 678-565-4626
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW004250
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License Number State | GA
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