Provider Demographics
NPI:1073208278
Name:JACKSON, REBECCA KEMP (MS, LCAS-A)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KEMP
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 SARDIS RD N STE 120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7722
Mailing Address - Country:US
Mailing Address - Phone:704-336-4844
Mailing Address - Fax:704-227-0691
Practice Address - Street 1:2401 SARDIS RD N STE 120
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-7722
Practice Address - Country:US
Practice Address - Phone:704-336-4844
Practice Address - Fax:704-227-0691
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)