Provider Demographics
NPI:1942747555
Name:JACKSON, JUANITA (LCPC)
Entity Type:Individual
Prefix:
First Name:JUANITA
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 1:1826 WOODLAWN DR STE 3
Mailing Address - Street 2:
Mailing Address - City:WOODLAWN
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4050
Mailing Address - Country:US
Mailing Address - Phone:301-367-1503
Mailing Address - Fax:443-451-8214
Practice Address - Street 1:1826 WOODLAWN DR STE 3
Practice Address - Street 2:
Practice Address - City:WOODLAWN
Practice Address - State:MD
Practice Address - Zip Code:21207-4050
Practice Address - Country:US
Practice Address - Phone:301-367-1503
Practice Address - Fax:443-451-8214
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-22
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC00202101YM0800X
MDLC7981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health