Provider Demographics
NPI:1205233863
Name:JACKSON, DARLA
Entity type:Individual
Prefix:MRS
First Name:DARLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:DARLA
Other - Middle Name:NICOLE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:104 BORDERS WAY STE 500
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8967
Mailing Address - Country:US
Mailing Address - Phone:910-689-5190
Mailing Address - Fax:
Practice Address - Street 1:106 PATRIOT WAY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5653
Practice Address - Country:US
Practice Address - Phone:910-689-5180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2025-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011852101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional