Provider Demographics
NPI:1497556088
Name:TIDEWATER MENTAL HEALTH COUNSELING PLLC
Entity type:Organization
Organization Name:TIDEWATER MENTAL HEALTH COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC-D
Authorized Official - Phone:484-599-1580
Mailing Address - Street 1:172 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2122
Mailing Address - Country:US
Mailing Address - Phone:484-599-1580
Mailing Address - Fax:
Practice Address - Street 1:172 W 21ST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-2122
Practice Address - Country:US
Practice Address - Phone:484-599-1580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)