Provider Demographics
NPI:1033736202
Name:JACKSON, TRINICIA RENEE LAVON (LPC)
Entity Type:Individual
Prefix:MISS
First Name:TRINICIA
Middle Name:RENEE LAVON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6530 DAVIDSON ST APT C1
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1732
Mailing Address - Country:US
Mailing Address - Phone:803-447-3949
Mailing Address - Fax:
Practice Address - Street 1:1105 BELLEVIEW ST STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1839
Practice Address - Country:US
Practice Address - Phone:803-250-5570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7802101YM0800X
SC7112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC2451Medicaid