Elijah Jagger Jackson, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

CW023481 Issued in PA

Practice address

201 S 13TH St Apt 1011
Philadelphia, PA 19107-5404

Phone

(631) 346-8485

NPI assigned

May 30, 2020

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

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

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1590796800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1685318400000",
    "number": "1669096244",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "201 S 13TH ST APT 1011",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191075404",
            "telephone_number": "631-346-8485"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 S 13TH ST APT 1011",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191075404",
            "telephone_number": "631-346-8485"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1500 Walnut St Ste 300",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191023502",
            "country_code": "US",
            "telephone_number": "215-563-7863",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "ELIJAH",
        "middle_name": "JAGGER",
        "credential": "LCSW",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-05-30",
        "last_updated": "2023-05-29",
        "certification_date": "2023-05-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "PA",
            "license": "CW023481",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Darryl Brett Jackson, M.D.
• Demeetra Jackson
• Donchelle Jackson
• Dvone Jackson, MD
• Elaine Jackson, LCPC
• Fatima Jackson
• Gabriella Jackson
• Gail M Jackson, MA
• Ikishia N Jackson, R.N
• Janeira Jackson

• Clinical Social Worker in Philadelphia, PA
• Providers in Philadelphia, PA by specialty
• Clinical Social Worker in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2023; 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.