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General NPI Number Information
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NPI Number | 1942686175
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Entity Type | Individual
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Provider Name | JACKSON K EDWARDS DMIN., LCSW
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Gender | Male
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Dates
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Enumeration Date | 08/11/2015
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Last Update Date | 06/26/2018
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Provider Practice Location Address
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Address Line | 650 HENDERSON DR STE 430
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City | CARTERSVILLE
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State | GA
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Zip | 30120-3760
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Country | US
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Telephone | 404-334-5859
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Fax |
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Provider Business Mailing Address
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Address Line | 1275 SHILOH RD NW STE 3030
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City | KENNESAW
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State | GA
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Zip | 30144-7186
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Country | US
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Telephone | 404-334-5859
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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 | MSW006645
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License Number State | GA
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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 | CSW006235
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License Number State | GA
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