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General NPI Number Information
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NPI Number | 1295051084
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Entity Type | Individual
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Provider Name | PRECIOUS TANYANIKA LAJOY JACKSON LPC
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Gender | Female
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Dates
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Enumeration Date | 04/19/2010
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Last Update Date | 03/26/2018
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Provider Practice Location Address
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Address Line | 1558 UNION RD STE F
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City | GASTONIA
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State | NC
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Zip | 28054-2215
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Country | US
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Telephone | 704-671-2609
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Fax | 704-671-4036
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Provider Business Mailing Address
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Address Line | 1509 DAVIS PARK RD
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City | GASTONIA
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State | NC
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Zip | 28052-5065
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Country | US
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Telephone | 704-747-6545
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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 | 7563
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License Number State | NC
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