Provider Demographics
NPI:1487148557
Name:JACKSON, AISHA MARIE (SWA)
Entity type:Individual
Prefix:MISS
First Name:AISHA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16314 SEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-3714
Mailing Address - Country:US
Mailing Address - Phone:216-318-4553
Mailing Address - Fax:
Practice Address - Street 1:3659 GREEN RD STE 220
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5715
Practice Address - Country:US
Practice Address - Phone:216-260-9022
Practice Address - Fax:216-260-9038
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
OHW.1300054104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker