Provider Demographics
NPI:1356423594
Name:JACKSON, JERRY EDWIN JR (LPC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:EDWIN
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3963 MARKET STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-362-9474
Mailing Address - Fax:910-362-9192
Practice Address - Street 1:3963 MARKET STREET
Practice Address - Street 2:SUITE A
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-362-9474
Practice Address - Fax:910-362-9192
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5109101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103285Medicaid