Provider Demographics
NPI:1275048167
Name:JACKSON, BRIAN M (LPC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 8549 SERENITY LANE
Mailing Address - Street 2:91150 COBURG INDUSTRIAL WAY
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408
Mailing Address - Country:US
Mailing Address - Phone:541-687-1110
Mailing Address - Fax:
Practice Address - Street 1:91150 COBURG INDUSTRIAL WAY SERENITY LANE
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-13803101YP2500X
ORC5715101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional