Provider Demographics
NPI:1316551591
Name:JACKSON, TOMESHA (LGPC)
Entity Type:Individual
Prefix:MRS
First Name:TOMESHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4213 HATTIES PROGRESS DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-6321
Mailing Address - Country:US
Mailing Address - Phone:202-505-0557
Mailing Address - Fax:
Practice Address - Street 1:2905 MITCHELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1385
Practice Address - Country:US
Practice Address - Phone:202-505-0557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10591101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health