Provider Demographics
NPI:1700761236
Name:JACKSON, CHANCE (LMSW)
Entity type:Individual
Prefix:
First Name:CHANCE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 FOUNTAIN ST APT C3
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1931
Mailing Address - Country:US
Mailing Address - Phone:203-500-2147
Mailing Address - Fax:
Practice Address - Street 1:197 DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3470
Practice Address - Country:US
Practice Address - Phone:203-500-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker