Provider Demographics
NPI:1043879315
Name:JACKSON, MYRNA C
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HAMLET HILL RD UNIT 602
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1510
Mailing Address - Country:US
Mailing Address - Phone:410-913-7000
Mailing Address - Fax:
Practice Address - Street 1:200 E. NORTH AVE
Practice Address - Street 2:RELATED SERVICES RM 210
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202
Practice Address - Country:US
Practice Address - Phone:443-642-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD047101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical