Provider Demographics
NPI:1194414698
Name:JACKSON, AMITY (LCSW)
Entity type:Individual
Prefix:
First Name:AMITY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PEARL ST STE 470
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-7122
Mailing Address - Country:US
Mailing Address - Phone:207-619-3356
Mailing Address - Fax:207-300-6085
Practice Address - Street 1:75 PEARL ST STE 470
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-7122
Practice Address - Country:US
Practice Address - Phone:207-619-3356
Practice Address - Fax:207-300-6085
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC220991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical