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General NPI Number Information
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NPI Number | 1194224923
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Entity Type | Individual
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Provider Name | DAMARIA EMAUNE JACKSON LPC
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Gender | Female
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Dates
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Enumeration Date | 02/07/2018
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Last Update Date | 12/09/2022
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Provider Practice Location Address
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Address Line | 10861 YANKEE ST
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City | DAYTON
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State | OH
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Zip | 45458-3574
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Country | US
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Telephone | 937-619-0800
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Fax |
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Provider Business Mailing Address
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Address Line | 1522 N MAIN ST APT A
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City | DAYTON
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State | OH
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Zip | 45405-4152
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Country | US
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Telephone |
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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 | 2204717
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License Number State | OH
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