Provider Demographics
NPI:1831412493
Name:JACKSON, LILLIAN MALINDA (LCAS)
Entity type:Individual
Prefix:MS
First Name:LILLIAN
Middle Name:MALINDA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:MS
Other - First Name:MALINDA
Other - Middle Name:D
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCAS
Mailing Address - Street 1:3000 FALSTAFF RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1813
Mailing Address - Country:US
Mailing Address - Phone:919-250-1260
Mailing Address - Fax:
Practice Address - Street 1:3000 FALSTAFF RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1813
Practice Address - Country:US
Practice Address - Phone:919-250-1260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1524101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)