MEDICARE: ERIN JACKSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.025913	IL
2	1041C0700X	Clinical Social Worker	10532	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10532	OTHER	CT	DEPARTMENT OF PUBLIC HEALTH

General Provider Information

NPI Number	:	1083171995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN JACKSON LCSW

Provider Business Mailing Address
First Line	:	114 WOODSIDE GRN APT 1B
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06905-4913
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 POST RD E # 265
Second Line	:
City	:	WESTPORT
State	:	CT
Zip	:	06880-4431
Country	:	US
Telephone Number	:	212-203-1773
Fax Number	:	646-665-4427

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2019
Last Update Date	:	07/09/2025

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