MEDICARE: JULIE JACKSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	66235	CA
2	101YP2500X	Professional Counselor	65379	TX

General Provider Information

NPI Number	:	1174139794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE JACKSON LCSW

Provider Business Mailing Address
First Line	:	8208 FARMINGTON CT
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78736-1744
Country	:	US
Telephone Number	:	714-588-0802
Fax Number	:

Provider Business Practice Location Address
First Line	:	8208 FARMINGTON CT
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78736-1744
Country	:	US
Telephone Number	:	714-588-0802
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2020
Last Update Date	:	09/18/2020

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