Provider Demographics
NPI:1184844763
Name:JACKSON, KATODRA (MS, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:KATODRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W CENTRAL TEXAS EXPY
Mailing Address - Street 2:STE. 208
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-2080
Mailing Address - Country:US
Mailing Address - Phone:254-289-4322
Mailing Address - Fax:254-634-5222
Practice Address - Street 1:100 W CENTRAL TEXAS EXPY
Practice Address - Street 2:STE. 208
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-2079
Practice Address - Country:US
Practice Address - Phone:254-289-4322
Practice Address - Fax:254-634-5222
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61137101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182509303Medicaid
TX182509301Medicaid