Provider Demographics
NPI:1154868958
Name:JACKSON, LINDA K
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E MOUND ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5571
Mailing Address - Country:US
Mailing Address - Phone:614-227-9694
Mailing Address - Fax:614-227-0370
Practice Address - Street 1:1336 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2081
Practice Address - Country:US
Practice Address - Phone:614-914-8781
Practice Address - Fax:614-914-8941
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS22915104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker