MEDICARE: DELQWAN RASHAWN JACKSON MSW, LCSWA

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	P016902	NC

General Provider Information

NPI Number	:	1386389807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DELQWAN RASHAWN JACKSON MSW, LCSWA

Provider Business Mailing Address
First Line	:	110 GLENBURNIE LN APT 103
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-3073
Country	:	US
Telephone Number	:	919-908-3072
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 GLENBURNIE LN APT 103
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-3073
Country	:	US
Telephone Number	:	919-908-3072
Fax Number	:

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

Provider Enumeration Date	:	04/29/2022
Last Update Date	:	04/29/2022

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