Provider Demographics
NPI:1699103242
Name:JACKSON, BETH Z (LCSW)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:Z
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:Z
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LLC
Mailing Address - Street 1:1520 LALEIAH DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9512
Mailing Address - Country:US
Mailing Address - Phone:404-295-5887
Mailing Address - Fax:
Practice Address - Street 1:6740 JAMESTOWN DR
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3030
Practice Address - Country:US
Practice Address - Phone:706-425-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0054241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical