MEDICARE: MR. CASEY JACKSON MSW, LICSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP00001054	WA
2	1041C0700X	Clinical Social Worker	LW00004476	WA

General Provider Information

NPI Number	:	1295943496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CASEY JACKSON MSW, LICSW

Provider Business Mailing Address
First Line	:	1124 W RIVERSIDE AVE
Second Line	:	SUITE LL2
City	:	SPOKANE
State	:	WA
Zip	:	99201-1132
Country	:	US
Telephone Number	:	509-981-9851
Fax Number	:

Provider Business Practice Location Address
First Line	:	1124 W RIVERSIDE AVE
Second Line	:	SUITE LL2
City	:	SPOKANE
State	:	WA
Zip	:	99201-1132
Country	:	US
Telephone Number	:	509-981-9851
Fax Number	:

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

Provider Enumeration Date	:	05/19/2007
Last Update Date	:	09/11/2025

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