Provider Demographics
NPI:1356774723
Name:JACKSON, DANITA A (LPC-IT)
Entity type:Individual
Prefix:
First Name:DANITA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10045 W LISBON AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2446
Mailing Address - Country:US
Mailing Address - Phone:414-358-7999
Mailing Address - Fax:414-358-7158
Practice Address - Street 1:10045 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2446
Practice Address - Country:US
Practice Address - Phone:414-358-7999
Practice Address - Fax:414-358-7158
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2014-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1854-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health