MEDICARE: ANGELA JACKSON LISW-CP

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
2	1041C0700X	Clinical Social Worker	13959	SC

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	:	1922511419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA JACKSON LISW-CP

Provider Business Mailing Address
First Line	:	1180 COLUMBIA AVE STE 101
Second Line	:
City	:	IRMO
State	:	SC
Zip	:	29063-2890
Country	:	US
Telephone Number	:	803-575-0579
Fax Number	:	803-830-3873

Provider Business Practice Location Address
First Line	:	1180 COLUMBIA AVE STE 101
Second Line	:
City	:	IRMO
State	:	SC
Zip	:	29063-2890
Country	:	US
Telephone Number	:	803-575-0579
Fax Number	:	803-830-3873

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

Provider Enumeration Date	:	11/07/2017
Last Update Date	:	04/14/2023

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