Active NPI
Brendalan Jackson, LCSW
- Social Worker
- Waldorf, MD
National Provider Identifier
1487319208
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Social Worker
- License
- Q3-0000338
- Practice address
- 9790 Frankfurt Dr
Waldorf, MD 20603-5346 - Phone
- (202) 459-8733
- NPI assigned
- Nov 5, 2021
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | LC20002422 | DC | |
| Clinical Social Worker | 1041C0700X | 0904014977 | VA | |
| Social Worker | 104100000X | Q3-0000338 | DE | Primary |
Addresses
Primary practice location
9790 Frankfurt Dr
Waldorf, MD 20603-5346
Mailing address
9790 Frankfurt Dr
Waldorf, MD 20603-5346
Phone (202) 459-8733
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| Q3-0000338 | DE | MD | Social Worker |
| LC20002422 | DC | MD | Clinical Social Worker |
| 0904014977 | VA | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1636070400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1705708800000",
"number": "1487319208",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9790 FRANKFURT DR",
"city": "WALDORF",
"state": "MD",
"postal_code": "206035346",
"telephone_number": "202-459-8733"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "9790 FRANKFURT DR",
"city": "WALDORF",
"state": "MD",
"postal_code": "206035346",
"telephone_number": "202-459-8733"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "BRENDALAN",
"credential": "LCSW",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2021-11-05",
"last_updated": "2024-01-20",
"certification_date": "2024-01-20",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "DC",
"license": "LC20002422",
"primary": false
},
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "VA",
"license": "0904014977",
"primary": false
},
{
"code": "104100000X",
"taxonomy_group": "",
"desc": "Social Worker",
"state": "DE",
"license": "Q3-0000338",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Waldorf, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 20, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.