Provider Demographics
NPI:1316089840
Name:JACKSON, SANDRA GORDON (LCSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:GORDON
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 1:2121 SAGE RD STE 180
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-4326
Mailing Address - Country:US
Mailing Address - Phone:713-622-7590
Mailing Address - Fax:713-622-7599
Practice Address - Street 1:2121 SAGE RD STE 180
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-4326
Practice Address - Country:US
Practice Address - Phone:713-622-7590
Practice Address - Fax:713-622-7599
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS020391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S79JMedicare ID - Type Unspecified