Provider Demographics
NPI:1326752973
Name:JACKSON, JANIS O'NEIL (LMHP)
Entity Type:Individual
Prefix:MRS
First Name:JANIS
Middle Name:O'NEIL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 MCINTOSH RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8425
Mailing Address - Country:US
Mailing Address - Phone:540-206-6412
Mailing Address - Fax:
Practice Address - Street 1:3522 WEBSTER RD
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:24064-1980
Practice Address - Country:US
Practice Address - Phone:540-977-6300
Practice Address - Fax:540-977-9523
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0730000220106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist