Provider Demographics
NPI:1649559410
Name:JACKSON, MARY GENNIFER (LCPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:GENNIFER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JACKSON
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 PARK CENTER COURT
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117
Mailing Address - Country:US
Mailing Address - Phone:410-356-3344
Mailing Address - Fax:410-356-4459
Practice Address - Street 1:904-A WASHINGTON ROAD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157
Practice Address - Country:US
Practice Address - Phone:410-751-9205
Practice Address - Fax:410-751-6191
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC0855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional