Provider Demographics
NPI:1659854503
Name:JACKSON, MARIA D (LMFT, LPC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-445-7787
Mailing Address - Fax:512-440-4059
Practice Address - Street 1:2410 E RIVERSIDE DR STE G3
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-3053
Practice Address - Country:US
Practice Address - Phone:512-804-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202800106H00000X
TX77298101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist