Basic Information
| Provider Information | |||||||||
| NPI: | 1821145525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 COMMERCE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074748311 | ||||||||
| FaxNumber: | 2074745148 | ||||||||
| Practice Location | |||||||||
| Address1: | 72 WINTHROP STREET | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076263478 | ||||||||
| FaxNumber: | 2076267586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MC8738 | ME | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LC11460 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.