Provider Demographics
NPI:1629195466
Name:JACKSON, ALICIA ALEXANDER (LCAS)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ALEXANDER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 POPE LAKE RD
Mailing Address - Street 2:PO BOX 473
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-5877
Mailing Address - Country:US
Mailing Address - Phone:910-671-1111
Mailing Address - Fax:910-671-4454
Practice Address - Street 1:2003 GODWIN AVE
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3149
Practice Address - Country:US
Practice Address - Phone:910-671-1111
Practice Address - Fax:910-671-4454
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)