Provider Demographics
NPI:1295159911
Name:JACKSON, CHANDA M (LCPC)
Entity type:Individual
Prefix:MRS
First Name:CHANDA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:CHANDA
Other - Middle Name:M
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:9402 W LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-8312
Mailing Address - Country:US
Mailing Address - Phone:725-800-1146
Mailing Address - Fax:
Practice Address - Street 1:9402 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-8312
Practice Address - Country:US
Practice Address - Phone:725-877-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-17
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21472101YP2500X
NVCP5102101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional