Provider Demographics
NPI:1982430419
Name:JACKSON, GRACE GLASGOW (LCSWA, LCASA)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:GLASGOW
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 POPLARWOOD CT STE 203
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-6445
Mailing Address - Country:US
Mailing Address - Phone:919-787-6131
Mailing Address - Fax:
Practice Address - Street 1:3117 POPLARWOOD CT STE 115
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1040
Practice Address - Country:US
Practice Address - Phone:919-787-6131
Practice Address - Fax:919-571-2932
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-30192101YA0400X
NCP0212811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)