Healthcare Provider Details

I. General information

NPI: 1225757578
Provider Name (Legal Business Name): TONIANDREA BARRATT JACKSON MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S EDWIN C MOSES BLVD
DAYTON OH
45417-3424
US

IV. Provider business mailing address

601 S EDWIN C MOSES BLVD
DAYTON OH
45417-3424
US

V. Phone/Fax

Practice location:
  • Phone: 100-000-0000
  • Fax:
Mailing address:
  • Phone: 100-000-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC015964
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: