Provider Demographics
NPI:1417454315
Name:JACKSON, CLARISSA (LCDC)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCDC
Mailing Address - Street 1:3080 W WASHINGTON ST STE B
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-3756
Mailing Address - Country:US
Mailing Address - Phone:254-965-5515
Mailing Address - Fax:
Practice Address - Street 1:3080 W WASHINGTON ST STE B
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3756
Practice Address - Country:US
Practice Address - Phone:254-965-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12992101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)