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General NPI Number Information
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NPI Number | 1083079511
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Entity Type | Individual
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Provider Name | TITANIA JACKSON
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Gender | Female
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Dates
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Enumeration Date | 12/29/2015
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Last Update Date | 04/17/2024
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Provider Practice Location Address
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Address Line | 610 N LOOP 336 E
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City | CONROE
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State | TX
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Zip | 77301-1437
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Country | US
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Telephone | 281-742-1142
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Fax |
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Provider Business Mailing Address
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Address Line | 115 BACLE DR
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City | CAMPTI
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State | LOUISIANA
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Zip | 71411
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Country | UM
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Telephone | 318-609-2776
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 68581
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License Number State | TX
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