Provider Demographics
NPI:1932679172
Name:JACKSON, VANESSA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11754 JOLLYVILLE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3948
Mailing Address - Country:US
Mailing Address - Phone:512-331-2700
Mailing Address - Fax:512-665-5796
Practice Address - Street 1:4220 MONTEREY OAKS BLVD STE 320
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1170
Practice Address - Country:US
Practice Address - Phone:512-331-2700
Practice Address - Fax:512-219-5097
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional