Provider Demographics
NPI:1508415043
Name:JACKSON, AZEL (LPC)
Entity Type:Individual
Prefix:
First Name:AZEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5005
Mailing Address - Country:US
Mailing Address - Phone:602-258-6797
Mailing Address - Fax:602-926-8399
Practice Address - Street 1:1209 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2692
Practice Address - Country:US
Practice Address - Phone:602-258-6797
Practice Address - Fax:602-926-8399
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-07
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-21976101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional