Provider Demographics
NPI:1700338142
Name:JACKSON, ELAINE (LCPC)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:325 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-2061
Mailing Address - Country:US
Mailing Address - Phone:202-780-5333
Mailing Address - Fax:
Practice Address - Street 1:325 CHERRY ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-2061
Practice Address - Country:US
Practice Address - Phone:202-780-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC00898101YM0800X
VA0701010327101YM0800X
MDLGP7431101YM0800X
MDLC9062101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health