Provider Demographics
NPI:1043459084
Name:JACKS, LYLE HENDRICKS (LMSW)
Entity type:Individual
Prefix:MS
First Name:LYLE
Middle Name:HENDRICKS
Last Name:JACKS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:LYLE
Other - Middle Name:HENDRICKS
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1807A E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-3841
Mailing Address - Country:US
Mailing Address - Phone:864-442-7482
Mailing Address - Fax:864-306-7977
Practice Address - Street 1:1807A E MAIN ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3841
Practice Address - Country:US
Practice Address - Phone:864-442-7482
Practice Address - Fax:864-306-7977
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5292104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker