MEDICARE: DEIDRE CO'LLETT JACKSON M.ED 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	101YP2500X	Professional Counselor	66355	TX

General Provider Information

NPI Number	:	1376944538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRE CO'LLETT JACKSON M.ED LPC

Provider Business Mailing Address
First Line	:	5959 WEST LOOP S STE 367
Second Line	:
City	:	BELLAIRE
State	:	TX
Zip	:	77401-2420
Country	:	US
Telephone Number	:	713-301-7461
Fax Number	:

Provider Business Practice Location Address
First Line	:	1826 LINGARD PARK CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77047-7514
Country	:	US
Telephone Number	:	713-301-7461
Fax Number	:

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

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	09/08/2014

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