Provider Demographics
NPI:1063070944
Name:JACKSON, SARAH BETH (LCSWA)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:BETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 KOOLER CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-4504
Mailing Address - Country:US
Mailing Address - Phone:336-964-0266
Mailing Address - Fax:
Practice Address - Street 1:1401 W ASH ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-1078
Practice Address - Country:US
Practice Address - Phone:919-947-8448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0132391041C0700X
NCPO12327104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker