MEDICARE: JAMES L JACKSON MSW,LICDC

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	101YM0800X	Mental Health Counselor	1101526	OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	101193	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101193	OTHER	OH	LICDC
2	1101526	OTHER	OH	LSW

General Provider Information

NPI Number	:	1598104044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES L JACKSON MSW,LICDC

Provider Business Mailing Address
First Line	:	9 MAIN ST.
Second Line	:
City	:	TROTWOOD
State	:	OH
Zip	:	45426
Country	:	US
Telephone Number	:	616-212-9802
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 E MAIN ST
Second Line	:
City	:	TROTWOOD
State	:	OH
Zip	:	45426-2830
Country	:	US
Telephone Number	:	616-212-9802
Fax Number	:

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

Provider Enumeration Date	:	06/18/2013
Last Update Date	:	01/09/2026

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