Individual
ANGELA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LISW-CP
Contact information
Practice address
1180 COLUMBIA AVE STE 101, IRMO, SC 29063-2890
(803) 575-0579
(803) 830-3873
Mailing address
1180 COLUMBIA AVE STE 101, IRMO, SC 29063-2890
(803) 575-0579
(803) 830-3873
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
1041C0700X
Clinical Social Worker
Primary
13959
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
SW1739
—
SC
Enumeration date
11/07/2017
Last updated
04/14/2023
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