Healthcare Provider Details

I. General information

NPI: 1770175507
Provider Name (Legal Business Name): JOHN ARTHUR JACKSON III MA, NCC, LCPC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W REDWOOD ST # 8082
BALTIMORE MD
21201-1708
US

IV. Provider business mailing address

306 W REDWOOD ST # 8082
BALTIMORE MD
21201-1708
US

V. Phone/Fax

Practice location:
  • Phone: 301-453-2417
  • Fax:
Mailing address:
  • Phone: 301-453-2417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: