Provider Demographics
NPI:1245881432
Name:JACKSON, JANINE (LCPC)
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18803 IMPULSE LN
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-1793
Mailing Address - Country:US
Mailing Address - Phone:301-519-7527
Mailing Address - Fax:
Practice Address - Street 1:13111 MORAN CT
Practice Address - Street 2:
Practice Address - City:NORTH POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20878-3922
Practice Address - Country:US
Practice Address - Phone:301-977-0824
Practice Address - Fax:240-597-0794
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9691101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional