Provider Demographics
NPI:1386513984
Name:JACKSON, MALLORY SUE (LPC-A, CSC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC-A, CSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 W LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:HARLETON
Mailing Address - State:TX
Mailing Address - Zip Code:75651-3726
Mailing Address - Country:US
Mailing Address - Phone:903-241-1272
Mailing Address - Fax:
Practice Address - Street 1:359 N CYPRESS ST STE 102
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-2348
Practice Address - Country:US
Practice Address - Phone:903-961-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-03
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX98631101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional