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General NPI Number Information
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NPI Number | 1871742791
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Entity Type | Individual
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Provider Name | CHARLES WAYNE JACKSON LPC
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Gender | Male
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Dates
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Enumeration Date | 09/16/2008
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Last Update Date | 09/19/2021
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Provider Practice Location Address
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Address Line | 16320 HUEBNER RD STE 200
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City | SAN ANTONIO
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State | TX
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Zip | 78248-1690
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Country | US
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Telephone | 210-425-5047
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Fax | 830-215-0223
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Provider Business Mailing Address
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Address Line | 16320 HUEBNER RD STE 200
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City | SAN ANTONIO
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State | TX
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Zip | 78248-1690
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Country | US
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Telephone | 210-425-5047
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Fax | 830-215-0223
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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 | 63795
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License Number State | TX
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