Provider Demographics
NPI:1841335916
Name:JACKSON, CAMILLA VAWN (LMFT, LPC)
Entity type:Individual
Prefix:MS
First Name:CAMILLA
Middle Name:VAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 GUADALUPE STREET #5C
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028
Mailing Address - Country:US
Mailing Address - Phone:713-240-4433
Mailing Address - Fax:
Practice Address - Street 1:1006 GUADALUPE ST APT 5C
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-4915
Practice Address - Country:US
Practice Address - Phone:830-496-1419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4732106H00000X
TX18405101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1841335916OtherNPI