Provider Demographics
NPI:1578000824
Name:JACKSON, DANIELLE MARIE (LPC)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:MARIE
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 1:2224 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8503 75TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7620
Practice Address - Country:US
Practice Address - Phone:262-654-9370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7473-125101YP2500X
WI3402226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor