Healthcare Provider Details

I. General information

NPI: 1639667611
Provider Name (Legal Business Name): SKYLETTE V JACKSON LCPC (MD), LPC (VA)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12302 SOMERSET AVE STE D
PRINCESS ANNE MD
21853-3099
US

IV. Provider business mailing address

12302 SOMERSET AVE
PRINCESS ANNE MD
21853-3099
US

V. Phone/Fax

Practice location:
  • Phone: 443-614-0829
  • Fax:
Mailing address:
  • Phone: 443-614-0829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701015474
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC17807
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1718
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: