Provider Demographics
NPI:1336713684
Name:JACKSON, DEJA DE'SHEA (LCSWA)
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:DE'SHEA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-4599
Mailing Address - Country:US
Mailing Address - Phone:910-489-6595
Mailing Address - Fax:
Practice Address - Street 1:34 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27527-4599
Practice Address - Country:US
Practice Address - Phone:919-243-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty