Provider Demographics
NPI:1295115749
Name:JACKSON, CELITTA ANN (LCPC)
Entity type:Individual
Prefix:MISS
First Name:CELITTA
Middle Name:ANN
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 1:26 ARK RD
Mailing Address - Street 2:
Mailing Address - City:LOTHIAN
Mailing Address - State:MD
Mailing Address - Zip Code:20711-2901
Mailing Address - Country:US
Mailing Address - Phone:410-980-2745
Mailing Address - Fax:301-439-1169
Practice Address - Street 1:1620 ELTON RD
Practice Address - Street 2:SUITE 206
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20903-1740
Practice Address - Country:US
Practice Address - Phone:301-439-7191
Practice Address - Fax:301-439-1169
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-30
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5556101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional