Provider Demographics
NPI:1912474685
Name:JACKSON, BAMBI (MSW)
Entity type:Individual
Prefix:MISS
First Name:BAMBI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8304 WOODIRON DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-3755
Mailing Address - Country:US
Mailing Address - Phone:770-299-9752
Mailing Address - Fax:
Practice Address - Street 1:8304 WOODIRON DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-3755
Practice Address - Country:US
Practice Address - Phone:770-299-9752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling