MEDICARE: MARY 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

General Provider Information

NPI Number	:	1508358813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JACKSON LPC

Provider Business Mailing Address
First Line	:	1530 E WILLIAMS FIELD RD STE 201
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85295-1825
Country	:	US
Telephone Number	:	480-561-6191
Fax Number	:

Provider Business Practice Location Address
First Line	:	1530 E WILLIAMS FIELD RD STE 201
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85295-1825
Country	:	US
Telephone Number	:	480-561-6191
Fax Number	:

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

Provider Enumeration Date	:	06/01/2018
Last Update Date	:	04/29/2021

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