Provider Demographics
NPI:1689488876
Name:JACKSON, CORA DENISE (DSW, LCSW, ACSW)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DSW, LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 KATHERINE DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9588
Mailing Address - Country:US
Mailing Address - Phone:601-665-4162
Mailing Address - Fax:888-398-1151
Practice Address - Street 1:1911 MISSION 66 STE B
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3762
Practice Address - Country:US
Practice Address - Phone:601-456-2598
Practice Address - Fax:855-830-3484
Is Sole Proprietor?:No
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC-113101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical