Provider Demographics
NPI:1245866102
Name:JACKSON, DODI ANN (MA, LPC)
Entity type:Individual
Prefix:
First Name:DODI
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-4302
Mailing Address - Country:US
Mailing Address - Phone:469-971-3438
Mailing Address - Fax:
Practice Address - Street 1:2770 MAIN ST STE 280
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-4523
Practice Address - Country:US
Practice Address - Phone:469-971-3438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-22
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77806101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX77806Medicaid