Provider Demographics
NPI:1457919979
Name:JACKSON, MARCIA ANTIONETTE (LCSW)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:ANTIONETTE
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 1:1350 S. JONES BLVD, STE 220
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146
Mailing Address - Country:US
Mailing Address - Phone:775-688-2489
Mailing Address - Fax:
Practice Address - Street 1:4530 S DECATUR BLVD, STE 201B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103
Practice Address - Country:US
Practice Address - Phone:702-486-5185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490191431041C0700X
NV10461-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty