Provider Demographics
NPI:1568755908
Name:JACKSON, MICHAEL WALKER (MS, MDIV,NCC, LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WALKER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS, MDIV,NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1168
Mailing Address - Street 2:1200 MEMORIAL DR
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-1168
Mailing Address - Country:US
Mailing Address - Phone:706-272-6480
Mailing Address - Fax:706-272-6109
Practice Address - Street 1:1200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2529
Practice Address - Country:US
Practice Address - Phone:706-272-6480
Practice Address - Fax:706-272-6109
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2756101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional