MEDICARE: ANISSA JACKSON LCDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	15987	TX

General Provider Information

NPI Number	:	1205679875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANISSA JACKSON LCDC

Provider Business Mailing Address
First Line	:	1601 ELM ST STE 4360
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-4701
Country	:	US
Telephone Number	:	562-296-2730
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 ELM ST STE 4360
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-4701
Country	:	US
Telephone Number	:	562-296-2730
Fax Number	:

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

Provider Enumeration Date	:	06/13/2024
Last Update Date	:	06/13/2024

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