Provider Demographics
NPI:1598918328
Name:JACKSON, JACQUELINE KAY (LCDC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SOUTH TYLER
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208
Mailing Address - Country:US
Mailing Address - Phone:214-942-5166
Mailing Address - Fax:214-942-6006
Practice Address - Street 1:201 SOUTH TYLER
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208
Practice Address - Country:US
Practice Address - Phone:214-942-5166
Practice Address - Fax:214-942-6006
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5461101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)