Provider Demographics
NPI:1265973812
Name:JACKSON, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 FORD ST
Mailing Address - Street 2:
Mailing Address - City:LLANO
Mailing Address - State:TX
Mailing Address - Zip Code:78643-2611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 RANCH ROAD 2900 STE 303
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:TX
Practice Address - Zip Code:78639-5853
Practice Address - Country:US
Practice Address - Phone:830-499-3744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74377101YP2500X
TX13344101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)