Provider Demographics
NPI:1326882721
Name:JACKSON, NIKKITA T (LISW)
Entity type:Individual
Prefix:
First Name:NIKKITA
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 49703
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-0703
Mailing Address - Country:US
Mailing Address - Phone:513-349-4035
Mailing Address - Fax:
Practice Address - Street 1:280 PROGRESS RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2316
Practice Address - Country:US
Practice Address - Phone:513-349-4035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.24051331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical