Provider Demographics
NPI:1518144369
Name:JACKSON, ANISE (LPC)
Entity Type:Individual
Prefix:
First Name:ANISE
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 1:1600 20TH ST S
Mailing Address - Street 2:SUITE D
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-4998
Mailing Address - Country:US
Mailing Address - Phone:205-447-2961
Mailing Address - Fax:
Practice Address - Street 1:1600 20TH ST S
Practice Address - Street 2:SUITE D
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-4998
Practice Address - Country:US
Practice Address - Phone:205-447-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2782101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2782OtherBOARD OF EXAMINERS IN COUNSELING