Provider Demographics
NPI:1144389917
Name:JACKSON, EDWARD L JR (LPC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:L
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 KEENELAND CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-3350
Mailing Address - Country:US
Mailing Address - Phone:314-921-2893
Mailing Address - Fax:
Practice Address - Street 1:7750 CLAYTON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1353
Practice Address - Country:US
Practice Address - Phone:314-647-7708
Practice Address - Fax:314-645-0359
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002498101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health