Provider Demographics
NPI:1295562890
Name:JACKSON, JOEL (LPC,CPO)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC,CPO
Other - Prefix:
Other - First Name:JOEL
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPO
Mailing Address - Street 1:214 POENISCH DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-2708
Mailing Address - Country:US
Mailing Address - Phone:307-258-6541
Mailing Address - Fax:
Practice Address - Street 1:214 POENISCH DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-2708
Practice Address - Country:US
Practice Address - Phone:307-258-6541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2206222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist