Provider Demographics
NPI:1508358813
Name:JACKSON, MARY (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
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 1:1530 E WILLIAMS FIELD RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1825
Mailing Address - Country:US
Mailing Address - Phone:480-561-6191
Mailing Address - Fax:
Practice Address - Street 1:1530 E WILLIAMS FIELD RD STE 201
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1825
Practice Address - Country:US
Practice Address - Phone:480-561-6191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health