Provider Demographics
NPI:1225440548
Name:JACKSON, TIERRA (LPCA, LMFTA, RMFTI)
Entity Type:Individual
Prefix:MRS
First Name:TIERRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPCA, LMFTA, RMFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 UTE TRL
Mailing Address - Street 2:
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925-3160
Mailing Address - Country:US
Mailing Address - Phone:828-994-7718
Mailing Address - Fax:
Practice Address - Street 1:4680 LIPSCOMB ST NE
Practice Address - Street 2:SUITE 10A
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2984
Practice Address - Country:US
Practice Address - Phone:321-433-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT2200106H00000X
NC9096A106H00000X
NCA10704101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional