MEDICARE: SHANA JUSTINE JACKSON LPC-ASSOCIATE

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	91515	TX

General Provider Information

NPI Number	:	1194402453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA JUSTINE JACKSON LPC-ASSOCIATE

Provider Business Mailing Address
First Line	:	9800 HILLWOOD PKWY STE 140
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76177-1532
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9800 HILLWOOD PKWY STE 140
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76177-1532
Country	:	US
Telephone Number	:	682-516-3287
Fax Number	:

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

Provider Enumeration Date	:	06/29/2023
Last Update Date	:	06/29/2023

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