Provider Demographics
NPI:1174278048
Name:JACKSON, ANTOINE DESHAWN (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:ANTOINE
Middle Name:DESHAWN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 WOODBRIDGE ST APT 338
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4763
Mailing Address - Country:US
Mailing Address - Phone:612-715-4071
Mailing Address - Fax:
Practice Address - Street 1:2120 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2649
Practice Address - Country:US
Practice Address - Phone:612-871-0099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3145101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health