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General NPI Number Information
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NPI Number | 1740840545
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Entity Type | Organization
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Legal Business Name | JACKSON COUNSELING ASSOCIATES
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Dates
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Enumeration Date | 06/14/2019
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Last Update Date | 06/14/2019
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Provider Practice Location Address
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Address Line | 4130 LINDEN AVE STE 250
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City | DAYTON
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State | OH
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Zip | 45432-3048
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Country | US
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Telephone | 937-681-9644
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Fax |
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Provider Business Mailing Address
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Address Line | 6504 SEMMES LN
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City | DAYTON
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State | OH
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Zip | 45424-7117
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Country | US
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Telephone | 937-681-9644
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CARROLL S JACKSON
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Credential | MSW,LISW-S
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Telephone | 937-681-9644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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