Provider Demographics
NPI:1992456784
Name:JACKSON, ADRIENNE MICHELLE (LISW-CP)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 FLINT WAY
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-5827
Mailing Address - Country:US
Mailing Address - Phone:803-920-3946
Mailing Address - Fax:
Practice Address - Street 1:29 FLINT WAY
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-5827
Practice Address - Country:US
Practice Address - Phone:803-920-3946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC162731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical