Provider Demographics
NPI:1184761561
Name:JACKSON, DEWANDA B (LPC, CPCS, EAU-C)
Entity type:Individual
Prefix:MRS
First Name:DEWANDA
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC, CPCS, EAU-C
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 1501
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-1007
Mailing Address - Country:US
Mailing Address - Phone:404-286-0054
Mailing Address - Fax:404-286-0064
Practice Address - Street 1:4319 COVINGTON HWY STE 110
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-1206
Practice Address - Country:US
Practice Address - Phone:404-286-0054
Practice Address - Fax:404-286-0064
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002390101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC002390OtherPROFESSIONAL COUNSELOR