MEDICARE: JORDAN JACKSON LPC-INTERN

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	:	1619501004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN JACKSON LPC-INTERN

Provider Business Mailing Address
First Line	:	345 WINECUP WAY
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78737-4562
Country	:	US
Telephone Number	:	832-517-6355
Fax Number	:

Provider Business Practice Location Address
First Line	:	3355 BEE CAVES RD STE 101
Second Line	:
City	:	WEST LAKE HILLS
State	:	TX
Zip	:	78746-6673
Country	:	US
Telephone Number	:	512-636-0104
Fax Number	:

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

Provider Enumeration Date	:	02/25/2020
Last Update Date	:	02/28/2020

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