MEDICARE: CLARISSA JACKSON

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		NC

General Provider Information

NPI Number	:	1851907364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA JACKSON

Provider Business Mailing Address
First Line	:	10140 HAWKEYE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-4536
Country	:	US
Telephone Number	:	704-458-8110
Fax Number	:

Provider Business Practice Location Address
First Line	:	10140 HAWKEYE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-4536
Country	:	US
Telephone Number	:	704-458-8110
Fax Number	:

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

Provider Enumeration Date	:	09/20/2020
Last Update Date	:	09/20/2020

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Directions to “ CLARISSA JACKSON ” Practice Location

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