Carroll S Jackson, L.I.S.W.

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

I.0009433 Issued in OH

Practice address

4130 Linden Ave
Suite 250
Dayton, OH 45432-3015

Phone

(937) 681-9644

NPI assigned

Nov 3, 2015

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OH

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Jackson Counseling Associates

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Dayton, OH
  • NPI 1740840545
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1446508800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1449792000000",
    "number": "1184097842",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6504 SEMMES LN",
            "city": "DAYTON",
            "state": "OH",
            "postal_code": "454247117",
            "telephone_number": "937-681-9644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4130 LINDEN AVE",
            "address_2": "SUITE 250",
            "city": "DAYTON",
            "state": "OH",
            "postal_code": "454323015",
            "telephone_number": "937-681-9644"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "CARROLL",
        "middle_name": "S",
        "credential": "L.I.S.W.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-11-03",
        "last_updated": "2015-12-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "OH",
            "license": "I.0009433",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Atiba Diarra Jackson, M.D.
• Bertha E Jackson
• Billy Jerome Jackson
• Brenda Lynn Jackson, B.S. BUSINESS
• Carl'Averis Jackson
• Chinah Lynn Jackson
• Courtney Faith Jackson
• Courtney L Jackson, SWA
• Cynthia Jackson, R.N. CDE
• Damaria Emaune Jackson, LPC

• Clinical Social Worker in Dayton, OH
• Providers in Dayton, OH by specialty
• Clinical Social Worker in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 11, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.