Provider Demographics
NPI:1730944273
Name:JACKSON, CRYSTAL RENE (LCSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:BRUNO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:123 MAIN STREET
Mailing Address - Street 2:60538
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062
Mailing Address - Country:US
Mailing Address - Phone:857-259-1722
Mailing Address - Fax:
Practice Address - Street 1:123 MAIN STREET
Practice Address - Street 2:60538
Practice Address - City:FLORENCE
Practice Address - State:MA
Practice Address - Zip Code:01062
Practice Address - Country:US
Practice Address - Phone:857-259-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2302411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical