Provider Demographics
NPI:1891352993
Name:JACKSON, LILLIAN L (LCPC)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:L
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:PO BOX 985
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-0985
Mailing Address - Country:US
Mailing Address - Phone:443-713-5746
Mailing Address - Fax:866-949-4549
Practice Address - Street 1:1311 S MAIN ST STE 302C
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5464
Practice Address - Country:US
Practice Address - Phone:667-770-6549
Practice Address - Fax:866-949-4549
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC12160101Y00000X, 101YA0400X, 101YP1600X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional