MEDICARE: KRISTAL 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	101YP2500X	Professional Counselor	74558	TX

General Provider Information

NPI Number	:	1437721032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTAL JACKSON LPC

Provider Business Mailing Address
First Line	:	5614 W GRAND PKWY S STE 102
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-5820
Country	:	US
Telephone Number	:	281-764-9816
Fax Number	:

Provider Business Practice Location Address
First Line	:	7811 PACIFIC SPRING LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77407-4031
Country	:	US
Telephone Number	:	281-704-1741
Fax Number	:

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

Provider Enumeration Date	:	07/13/2021
Last Update Date	:	07/13/2021

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