Provider Demographics
NPI:1134632441
Name:JACKSON, BRENTOM E (LPC)
Entity type:Individual
Prefix:MR
First Name:BRENTOM
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6961 NE LOOP 820 APT 423
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-6694
Mailing Address - Country:US
Mailing Address - Phone:512-786-3107
Mailing Address - Fax:
Practice Address - Street 1:6961 NE LOOP 820 APT 423
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-6694
Practice Address - Country:US
Practice Address - Phone:512-786-3107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68645101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional