Provider Demographics
NPI:1083171896
Name:COTTRELL-JACKSON, WILLIAM (LPC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:COTTRELL-JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:BILLY
Other - Middle Name:
Other - Last Name:COTTRELL-JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:10356 FALCON GATE LOOP APT 102
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5825
Mailing Address - Country:US
Mailing Address - Phone:404-490-0221
Mailing Address - Fax:
Practice Address - Street 1:10356 FALCON GATE LOOP APT 102
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5825
Practice Address - Country:US
Practice Address - Phone:404-490-0221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006552101Y00000X
GALPC0129101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty