Kim Elaine Jackson, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

LW61326871 Issued in WA

Practice address

4909 Davenport Ave
Oakland, CA 94619-2920

Phone

(206) 549-4668

Fax

(206) 568-7043

NPI assigned

Sep 22, 2019

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Ms. Kim Elaine Jackson Professional name

Medicare fee-for-service enrollment

Enrolled in DC, WA2 enrollments

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 2

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

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.

• Grow Healthcare Group PA

  • Mental Health Counselor
  • Miami, FL
  • NPI 1245845932

  Clinical, DC, WA

  Medicare reassignment NPD
• Uplift Health Technologies, Inc.

  • Adult Mental Health Clinic/Center
  • Arlington, VA
  • NPI 1770189243

  DC

  Medicare reassignment NPD

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

{
    "created_epoch": "1569110400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712102400000",
    "number": "1184275166",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1253 C ST SE",
            "city": "WASHINGTON",
            "state": "DC",
            "postal_code": "200032202",
            "telephone_number": "206-549-4668",
            "fax_number": "206-568-7043"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4909 DAVENPORT AVE",
            "city": "OAKLAND",
            "state": "CA",
            "postal_code": "946192920",
            "telephone_number": "206-549-4668",
            "fax_number": "206-568-7043"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KIM",
        "middle_name": "ELAINE",
        "credential": "LICSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-09-22",
        "last_updated": "2024-04-03",
        "certification_date": "2024-04-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "DC",
            "license": "LC50082406",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "WA",
            "license": "LW61326871",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2229463",
            "state": "DC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2229463",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KIM",
            "last_name": "JACKSON",
            "middle_name": "ELAINE",
            "prefix": "MS.",
            "credential": "LICSW",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Isaiah Jackson
• Jenee Jackson
• Jill Michelle Jackson, MFT
• Kayla Jackson
• Kenneth Edward Jackson
• Lacena T Jackson
• Latisha Nichole Jackson
• Leonard Jackson Jr.
• Mable Lee Jackson
• Marina Marcia Jackson, MFT

• Clinical Social Worker in Oakland, CA
• Providers in Oakland, CA by specialty
• Clinical Social Worker in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 3, 2024; 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.