Provider Demographics
NPI:1881930006
Name:JACKSON, BETHENA M (CSAC, LCAS-A)
Entity type:Individual
Prefix:MS
First Name:BETHENA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CSAC, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 PEAR TREE LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-6280
Mailing Address - Country:US
Mailing Address - Phone:919-633-8360
Mailing Address - Fax:
Practice Address - Street 1:2604 CARVER ST
Practice Address - Street 2:SUITE C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2796
Practice Address - Country:US
Practice Address - Phone:919-682-4771
Practice Address - Fax:919-683-2641
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-15
Last Update Date:2012-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)