Provider Demographics
NPI:1760138994
Name:JACKSON, LASHAY (ALC)
Entity Type:Individual
Prefix:
First Name:LASHAY
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 1:2053 ARROWGRASS DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-4705
Mailing Address - Country:US
Mailing Address - Phone:404-998-3983
Mailing Address - Fax:
Practice Address - Street 1:557 GLOVER AVE STE 3
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2070
Practice Address - Country:US
Practice Address - Phone:334-308-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor