MEDICARE: ANDREA LANE JACKSON LICSW, 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	104100000X	Social Worker	087822	NY
2	1041C0700X	Clinical Social Worker	0904017420	VA
3	1041C0700X	Clinical Social Worker	091378	NY
4	1041C0700X	Clinical Social Worker	LC200003614	DC

General Provider Information

NPI Number	:	1679003099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA LANE JACKSON LICSW, LCSW

Provider Business Mailing Address
First Line	:	1763 COLUMBIA RD NW STE 175
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-2891
Country	:	US
Telephone Number	:	202-381-3997
Fax Number	:

Provider Business Practice Location Address
First Line	:	1763 COLUMBIA RD NW STE 175
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-2891
Country	:	US
Telephone Number	:	202-318-3997
Fax Number	:	202-318-0501

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

Provider Enumeration Date	:	06/18/2017
Last Update Date	:	08/18/2025

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