Provider Demographics
NPI:1649700329
Name:JACKSON, MYCHA I (LPC)
Entity type:Individual
Prefix:
First Name:MYCHA
Middle Name:I
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4866 GREENBRIER MOSSYDALE RD
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-6523
Mailing Address - Country:US
Mailing Address - Phone:803-800-1701
Mailing Address - Fax:
Practice Address - Street 1:4866 GREENBRIER MOSSYDALE RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-6523
Practice Address - Country:US
Practice Address - Phone:803-800-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9508101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3335OtherMEDICARE PIN
SC421504Medicaid