Provider Demographics
NPI:1679227748
Name:JACKSON, EMILY (ALC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9869 PULASKI PIKE UNIT C
Mailing Address - Street 2:
Mailing Address - City:TONEY
Mailing Address - State:AL
Mailing Address - Zip Code:35773-7201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9869 PULASKI PIKE UNIT C
Practice Address - Street 2:
Practice Address - City:TONEY
Practice Address - State:AL
Practice Address - Zip Code:35773-7201
Practice Address - Country:US
Practice Address - Phone:256-850-4091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04779101YM0800X
RBT-21-190282106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALALC04779OtherALABAMA BOARD OF EXAMINERS IN COUNSELING
RBT-21-190282OtherBACB