Provider Demographics
NPI:1588327555
Name:JACKSON, TABETHA NICOLE (LCSW)
Entity type:Individual
Prefix:MISS
First Name:TABETHA
Middle Name:NICOLE
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 1:513 AMERSON CT # B
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-1151
Mailing Address - Country:US
Mailing Address - Phone:252-955-3744
Mailing Address - Fax:
Practice Address - Street 1:513 AMERSON CT # B
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-1151
Practice Address - Country:US
Practice Address - Phone:252-955-3744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0079071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical