MEDICARE: MISS CAITLIN REBECCA 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	220615	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841963485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CAITLIN REBECCA JACKSON LCSW

Provider Business Mailing Address
First Line	:	6 MARIGOLD LN
Second Line	:
City	:	ANDOVER
State	:	MA
Zip	:	01810-4424
Country	:	US
Telephone Number	:	339-999-6440
Fax Number	:

Provider Business Practice Location Address
First Line	:	2B HAROLD ST
Second Line	:
City	:	HARWICH PORT
State	:	MA
Zip	:	02646-1517
Country	:	US
Telephone Number	:	508-418-8504
Fax Number	:

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

Provider Enumeration Date	:	07/29/2021
Last Update Date	:	07/29/2021

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