Provider Demographics
NPI:1013228519
Name:JACKSON, LORA J (MS, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:10309 GREENWOOD STREET
Mailing Address - City:ELLERSLIE
Mailing Address - State:MD
Mailing Address - Zip Code:21529-0398
Mailing Address - Country:US
Mailing Address - Phone:301-697-6199
Mailing Address - Fax:
Practice Address - Street 1:110 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-1131
Practice Address - Country:US
Practice Address - Phone:814-652-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005514101Y00000X
MDLC2939101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor