Provider Demographics
NPI:1851869697
Name:JACKSON, KEISHA (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 WELFORD MANOR DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6045
Mailing Address - Country:US
Mailing Address - Phone:202-486-2152
Mailing Address - Fax:
Practice Address - Street 1:5801 ALLENTOWN RD STE 310
Practice Address - Street 2:
Practice Address - City:CAMP SPRINGS
Practice Address - State:MD
Practice Address - Zip Code:20746-4564
Practice Address - Country:US
Practice Address - Phone:240-392-2876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8380101YM0800X
MDLC11445101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty