Healthcare Provider Details

I. General information

NPI: 1629565361
Provider Name (Legal Business Name): PATRICIA KATHERINE JACKSON LCMHC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 W CONE BLVD STE 234
GREENSBORO NC
27408-4062
US

IV. Provider business mailing address

1301 CAROLINA ST STE 114
GREENSBORO NC
27401-1090
US

V. Phone/Fax

Practice location:
  • Phone: 336-585-7012
  • Fax:
Mailing address:
  • Phone: 704-340-1765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13613
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA13613
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: