Provider Demographics
NPI:1205679875
Name:JACKSON, ANISSA (LCDC)
Entity type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 ELM ST STE 4360
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4701
Mailing Address - Country:US
Mailing Address - Phone:562-296-2730
Mailing Address - Fax:
Practice Address - Street 1:1601 ELM ST STE 4360
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4701
Practice Address - Country:US
Practice Address - Phone:562-296-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15987101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)