Provider Demographics
NPI:1093416224
Name:TALBERT JACKSON, CHARLES HENRY (LGPC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HENRY
Last Name:TALBERT JACKSON
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 LEEGATE RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-1211
Mailing Address - Country:US
Mailing Address - Phone:301-775-7374
Mailing Address - Fax:
Practice Address - Street 1:8120 WOODMONT AVE STE 840
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2743
Practice Address - Country:US
Practice Address - Phone:240-618-2889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11776101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional