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General NPI Number Information
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NPI Number | 1689479412
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Entity Type | Individual
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Provider Name | MARIO JACKSON
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Gender | Male
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Dates
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Enumeration Date | 02/17/2025
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Last Update Date | 02/17/2025
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Provider Practice Location Address
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Address Line | 4831 OLD CHARLOTTE HWY STE A
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City | MONROE
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State | NC
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Zip | 28110-6300
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Country | US
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Telephone | 704-575-2142
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Fax |
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Provider Business Mailing Address
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Address Line | 1736 DICKERSON BLVD STE F
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City | MONROE
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State | NC
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Zip | 28110-2833
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Country | US
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Telephone | 704-575-2142
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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 | 230958
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License Number State | NC
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