Provider Demographics
NPI:1114101896
Name:JACKSON, ANN PATRICIA (LPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:PATRICIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ELKIN BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-3159
Mailing Address - Country:US
Mailing Address - Phone:336-835-1000
Mailing Address - Fax:336-835-1075
Practice Address - Street 1:200 ELKIN BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-3159
Practice Address - Country:US
Practice Address - Phone:336-835-1000
Practice Address - Fax:336-835-1075
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4131302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization