Provider Demographics
NPI:1093066037
Name:JACKSON, ISAAC L (LCAS-A)
Entity Type:Individual
Prefix:MR
First Name:ISAAC
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W ELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-2801
Mailing Address - Country:US
Mailing Address - Phone:910-848-1638
Mailing Address - Fax:910-848-1639
Practice Address - Street 1:113 W ELWOOD AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-2801
Practice Address - Country:US
Practice Address - Phone:910-848-1638
Practice Address - Fax:910-848-1639
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2199-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)