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General NPI Number Information
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NPI Number | 1720589773
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Entity Type | Individual
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Provider Name | KEIJUANNA JANEE JACKSON LMSW
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Gender | Female
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Dates
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Enumeration Date | 02/26/2018
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Last Update Date | 02/26/2018
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Provider Practice Location Address
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Address Line | 2928 W 5TH ST
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City | FORT WORTH
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State | TX
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Zip | 76107-2242
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Country | US
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Telephone | 817-332-6348
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Fax |
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Provider Business Mailing Address
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Address Line | 2340 CAP ROCK LN
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City | FORT WORTH
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State | TX
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Zip | 76133-8906
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Country | US
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Telephone | 219-789-1899
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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 | 59218
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License Number State | TX
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