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General NPI Number Information
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NPI Number | 1740849314
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Entity Type | Individual
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Provider Name | NICOLE JACKSON LCSW-C
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Gender | Female
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Dates
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Enumeration Date | 06/07/2019
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Last Update Date | 09/13/2021
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Provider Practice Location Address
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Address Line | 16220 FREDERICK RD STE 310
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City | GAITHERSBURG
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State | MD
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Zip | 20877-4020
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Country | US
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Telephone | 301-358-4388
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Fax |
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Provider Business Mailing Address
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Address Line | 7474 GREENWAY CENTER DR SUITE 730
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City | GREENBELT
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State | MD
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Zip | 20770-3523
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Country | US
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Telephone |
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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 | 24876
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 24876
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License Number State | MD
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