Provider Demographics
NPI:1407743164
Name:JACKSON, JOHNATHON DEAN (LCSWA)
Entity type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:DEAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-9537
Mailing Address - Country:US
Mailing Address - Phone:910-988-5323
Mailing Address - Fax:
Practice Address - Street 1:351 WAGONER DR STE 411
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4608
Practice Address - Country:US
Practice Address - Phone:910-994-2818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0220361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty