Provider Demographics
NPI:1386986073
Name:JACKSON, AMY (MSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MUIRS CHAPEL RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-6173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 CAPCOM AVE STE 101
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6537
Practice Address - Country:US
Practice Address - Phone:919-792-3967
Practice Address - Fax:919-761-5026
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0089721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical