MEDICARE: ANTOINETTE JACKSON LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LGPC10802	MD
2	101YP2500X	Professional Counselor	LGPC00603	DC
3	101YP2500X	Professional Counselor	PRC200001270	DC

General Provider Information

NPI Number	:	1275187387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTOINETTE JACKSON LPC

Provider Business Mailing Address
First Line	:	5048 11TH ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20017-2848
Country	:	US
Telephone Number	:	202-570-5774
Fax Number	:

Provider Business Practice Location Address
First Line	:	5048 11TH ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20017-2848
Country	:	US
Telephone Number	:	202-570-5774
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2019
Last Update Date	:	11/16/2021

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Directions to “ ANTOINETTE JACKSON LPC” Practice Location

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