Provider Demographics
NPI:1871040469
Name:JACKSON, JULIE R (MED, NCC, LPCA)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED, NCC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2294 HANOVER CT
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-6486
Mailing Address - Country:US
Mailing Address - Phone:704-877-8663
Mailing Address - Fax:
Practice Address - Street 1:7810 PRINEVILLE-MATHEWS ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226
Practice Address - Country:US
Practice Address - Phone:704-877-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12451101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional