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General NPI Number Information
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NPI Number | 1417070921
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Entity Type | Individual
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Provider Name | STEPHANIE JACKSON MA, LSSP, LPC
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Gender | Female
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 12/21/2018
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Provider Practice Location Address
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Address Line | 1214 18TH ST STE B1
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City | HONDO
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State | TX
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Zip | 78861-1753
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Country | US
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Telephone | 713-303-7292
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Fax | 830-584-0633
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Provider Business Mailing Address
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Address Line | PO BOX 1272
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City | PEARSALL
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State | TX
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Zip | 78061-1272
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Country | US
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Telephone | 713-303-7292
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Fax | 830-334-3989
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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 | 20255
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 20255
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License Number State | TX
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