Provider Demographics
NPI:1225157498
Name:JACKSON, NATOYA (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:NATOYA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-2757
Mailing Address - Country:US
Mailing Address - Phone:336-996-0631
Mailing Address - Fax:336-996-5712
Practice Address - Street 1:121 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2757
Practice Address - Country:US
Practice Address - Phone:336-996-0631
Practice Address - Fax:336-996-5712
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5317101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional