Provider Demographics
NPI:1396010211
Name:JACKSON, LAUREN INNES (PHD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:INNES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7810 AMHERST AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-8201
Mailing Address - Country:US
Mailing Address - Phone:214-794-8507
Mailing Address - Fax:972-867-3402
Practice Address - Street 1:5555 ARAPAHO RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-3442
Practice Address - Country:US
Practice Address - Phone:972-661-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34654103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical