Provider Demographics
NPI:1669278321
Name:JACKSON, MARGERAE R (LPC)
Entity type:Individual
Prefix:MS
First Name:MARGERAE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12601 INNOVAR CIR APT 6309
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-4725
Mailing Address - Country:US
Mailing Address - Phone:989-488-8047
Mailing Address - Fax:
Practice Address - Street 1:12601 INNOVAR CIR APT 6309
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-4725
Practice Address - Country:US
Practice Address - Phone:989-488-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401224136101YP2500X
TX88583101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional