Healthcare Provider Details

I. General information

NPI: 1356275028
Provider Name (Legal Business Name): LENA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5457 TWIN KNOLLS RD STE 300
COLUMBIA MD
21045-3296
US

IV. Provider business mailing address

5457 TWIN KNOLLS RD STE 300 PMB: #1588
COLUMBIA MD
21045-3296
US

V. Phone/Fax

Practice location:
  • Phone: 301-795-5286
  • Fax:
Mailing address:
  • Phone: 410-870-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP17091
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: