Provider Demographics
NPI:1740840545
Name:JACKSON COUNSELING ASSOCIATES
Entity type:Organization
Organization Name:JACKSON COUNSELING ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LISW-S
Authorized Official - Phone:937-681-9644
Mailing Address - Street 1:6504 SEMMES LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-7117
Mailing Address - Country:US
Mailing Address - Phone:937-681-9644
Mailing Address - Fax:
Practice Address - Street 1:4130 LINDEN AVE STE 250
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-3048
Practice Address - Country:US
Practice Address - Phone:937-681-9644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)