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General NPI Number Information
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NPI Number | 1194267476
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Entity Type | Individual
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Provider Name | ANGELA DECARLA JACKSON PH.D., LCPC, LMHC
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Gender | Female
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Dates
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Enumeration Date | 11/17/2016
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Last Update Date | 06/25/2025
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Provider Practice Location Address
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Address Line | 1251 N EDDY ST STE 200
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City | SOUTH BEND
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State | IN
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Zip | 46617-1478
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Country | US
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Telephone | 312-798-9755
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Fax |
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Provider Business Mailing Address
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Address Line | 1251 N EDDY ST STE 200
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City | SOUTH BEND
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State | IN
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Zip | 46617-1478
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Country | US
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Telephone | 312-798-9755
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.011258
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 39004648A
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License Number State | IN
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