Provider Demographics
NPI:1376944538
Name:JACKSON, DEIDRE CO'LLETT (MED LPC)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:CO'LLETT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 WEST LOOP S STE 367
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-2420
Mailing Address - Country:US
Mailing Address - Phone:713-301-7461
Mailing Address - Fax:
Practice Address - Street 1:1826 LINGARD PARK CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77047-7514
Practice Address - Country:US
Practice Address - Phone:713-301-7461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66355101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional