Healthcare Provider Details

I. General information

NPI: 1396326625
Provider Name (Legal Business Name): JANEL JACKSON LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 W UNIVERSITY DR STE 102
MESA AZ
85201-5650
US

IV. Provider business mailing address

708 N COUNTRY CLUB DR
MESA AZ
85201-4932
US

V. Phone/Fax

Practice location:
  • Phone: 480-527-0337
  • Fax:
Mailing address:
  • Phone: 480-604-4730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC08520T
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-164780
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: