Provider Demographics
NPI:1932453636
Name:JACKSON, KWAJERA ZAKIYAH (MSW, LCSW-C)
Entity type:Individual
Prefix:MS
First Name:KWAJERA
Middle Name:ZAKIYAH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 BEDFORD AVE UNIT 5704
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21282-7501
Mailing Address - Country:US
Mailing Address - Phone:443-272-1526
Mailing Address - Fax:
Practice Address - Street 1:1325 BEDFORD AVE UNIT 5704
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21282-7501
Practice Address - Country:US
Practice Address - Phone:443-272-1526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3700C-12101041C0700X
MD149921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD114312300Medicaid