Provider Demographics
NPI:1487319208
Name:JACKSON, BRENDALAN (LCSW)
Entity type:Individual
Prefix:
First Name:BRENDALAN
Middle Name:
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 1:9790 FRANKFURT DR
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-5346
Mailing Address - Country:US
Mailing Address - Phone:202-459-8733
Mailing Address - Fax:
Practice Address - Street 1:9790 FRANKFURT DR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-5346
Practice Address - Country:US
Practice Address - Phone:202-459-8733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC200024221041C0700X
VA09040149771041C0700X
DEQ3-0000338104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical