Provider Demographics
NPI:1366636284
Name:BLANTON, JACKIE DENISE (LPC)
Entity Type:Individual
Prefix:MISS
First Name:JACKIE
Middle Name:DENISE
Last Name:BLANTON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:POSITIVE
Other - Middle Name:
Other - Last Name:DIRECTIONS, LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-0096
Mailing Address - Country:US
Mailing Address - Phone:864-978-7086
Mailing Address - Fax:
Practice Address - Street 1:2375 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1434
Practice Address - Country:US
Practice Address - Phone:864-978-7086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2765101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional