Healthcare Provider Details

I. General information

NPI: 1316551591
Provider Name (Legal Business Name): TOMESHA JACKSON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16900 SCIENCE DR STE 208-210
BOWIE MD
20715-4401
US

IV. Provider business mailing address

4213 HATTIES PROGRESS DR
BOWIE MD
20720-6321
US

V. Phone/Fax

Practice location:
  • Phone: 240-614-2133
  • Fax:
Mailing address:
  • Phone: 202-505-0557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC12091
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: