Provider Demographics
NPI:1962091801
Name:JACKSON, COURTNEY DANIELLE (LMSW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:DANIELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BYRD ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-1943
Mailing Address - Country:US
Mailing Address - Phone:516-304-0522
Mailing Address - Fax:
Practice Address - Street 1:28 BYRD ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-1943
Practice Address - Country:US
Practice Address - Phone:516-304-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
094810104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker