Provider Demographics
NPI:1225521313
Name:JACKSON, FELICIA LYNETTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:FELICIA
Middle Name:LYNETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 CLAIRMONT RD STE 305A
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1258
Mailing Address - Country:US
Mailing Address - Phone:404-692-7005
Mailing Address - Fax:
Practice Address - Street 1:1201 CLAIRMONT RD STE 305A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1258
Practice Address - Country:US
Practice Address - Phone:404-692-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2022-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024378103T00000X
GA004434103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist