Provider Demographics
NPI:1669979738
Name:JACKSON, TAMICKCO MARIA DEEN (MENTAL HEALTH COUNSE)
Entity type:Individual
Prefix:
First Name:TAMICKCO
Middle Name:MARIA DEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MENTAL HEALTH COUNSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3171
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789
Mailing Address - Country:US
Mailing Address - Phone:808-633-0405
Mailing Address - Fax:
Practice Address - Street 1:941 KAMEHAMEHA HWY STE 204
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-2516
Practice Address - Country:US
Practice Address - Phone:808-633-0405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMHC-418101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health