Provider Demographics
NPI:1033740188
Name:JACKSON, DANA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:MARIE
Other - Last Name:CLEMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:186 E 1800 N STE 1
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2245
Mailing Address - Country:US
Mailing Address - Phone:435-213-3026
Mailing Address - Fax:
Practice Address - Street 1:186 E 1800 N STE 1
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2245
Practice Address - Country:US
Practice Address - Phone:435-213-3026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT827080635011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical