Provider Demographics
NPI:1881350551
Name:JACKSON, SANDRA LYNNE (LPC)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LYNNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1572
Mailing Address - Country:US
Mailing Address - Phone:770-251-5873
Mailing Address - Fax:770-304-2201
Practice Address - Street 1:121 JACKSON ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1572
Practice Address - Country:US
Practice Address - Phone:770-251-5873
Practice Address - Fax:770-304-2201
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC0012685101YP2500X
GALPC012399101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional