Provider Demographics
NPI:1699887166
Name:JACKSON, JERRY MICHAEL (MSW, ACSW)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MICHAEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3723 NE 150TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-7828
Mailing Address - Country:US
Mailing Address - Phone:206-367-3351
Mailing Address - Fax:206-367-0547
Practice Address - Street 1:11016 NE 2ND PL
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5830
Practice Address - Country:US
Practice Address - Phone:425-455-0348
Practice Address - Fax:206-367-0547
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00004286101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW00004286OtherLICENSED SOCIAL WORKER