Healthcare Provider Details

I. General information

NPI: 1336052729
Provider Name (Legal Business Name): GILLIAN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19901 W CATAWBA AVE STE 202
CORNELIUS NC
28031-4043
US

IV. Provider business mailing address

3820 LAMPASAS LN
CHARLOTTE NC
28214-3812
US

V. Phone/Fax

Practice location:
  • Phone: 980-728-1008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP024540
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: