Provider Demographics
NPI:1568037190
Name:MINDY R. JACKSON, LPC
Entity Type:Organization
Organization Name:MINDY R. JACKSON, LPC
Other - Org Name:WILLOWBROOK COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MINNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:276-613-4273
Mailing Address - Street 1:100 ARDMORE ST STE 304
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-5802
Mailing Address - Country:US
Mailing Address - Phone:540-820-4242
Mailing Address - Fax:
Practice Address - Street 1:100 ARDMORE ST STE 304
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-5802
Practice Address - Country:US
Practice Address - Phone:540-820-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health