Provider Demographics
NPI:1194765289
Name:JACKSON, DIANE CATHLEEN (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:CATHLEEN
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 1:806 HAY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5312
Mailing Address - Country:US
Mailing Address - Phone:910-822-3333
Mailing Address - Fax:910-822-3336
Practice Address - Street 1:806 HAY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5312
Practice Address - Country:US
Practice Address - Phone:910-822-3333
Practice Address - Fax:910-822-3336
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0045761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC136K7OtherBCBS OF NC
NC6003734Medicaid