Provider Demographics
NPI:1497069900
Name:JACKSON, WANDA ELIZABETH
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LGPC
Mailing Address - Street 1:4006 JEFFERY CT
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-3073
Mailing Address - Country:US
Mailing Address - Phone:410-515-0443
Mailing Address - Fax:
Practice Address - Street 1:2018 ROCK SPRING RD
Practice Address - Street 2:A6
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2631
Practice Address - Country:US
Practice Address - Phone:410-838-2493
Practice Address - Fax:410-838-2547
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP3349101YP2500X
MD101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional