Provider Demographics
NPI:1639656200
Name:JACKSON, NASHOTA LYNN (LCPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:NASHOTA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-4803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 RIDGELY AVE
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1069
Practice Address - Country:US
Practice Address - Phone:410-803-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MDLC10411101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health