Provider Demographics
NPI:1437721032
Name:JACKSON, KRISTAL (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5614 W GRAND PKWY S STE 102
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-5820
Mailing Address - Country:US
Mailing Address - Phone:281-764-9816
Mailing Address - Fax:
Practice Address - Street 1:7811 PACIFIC SPRING LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-4031
Practice Address - Country:US
Practice Address - Phone:281-704-1741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74558101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional