Provider Demographics
NPI:1508397548
Name:JACKSON, JAQUINDA
Entity Type:Individual
Prefix:
First Name:JAQUINDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 SE MAIN ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-2653
Mailing Address - Country:US
Mailing Address - Phone:864-451-9443
Mailing Address - Fax:
Practice Address - Street 1:638 TIMBER WALK DR
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-4554
Practice Address - Country:US
Practice Address - Phone:864-451-9443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6505101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor