MEDICARE: DR. T. L. JACKSON PSY.D.

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	103TC0700X	Clinical Psychologist	34857	TX

General Provider Information

NPI Number	:	1215228341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. T. L. JACKSON PSY.D.

Provider Business Mailing Address
First Line	:	4447 N CENTRAL EXPY
Second Line	:	STE 110 PMB 231
City	:	DALLAS
State	:	TX
Zip	:	75205-4245
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2506 S LANCASTER RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-2532
Country	:	US
Telephone Number	:	214-356-0335
Fax Number	:

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

Provider Enumeration Date	:	04/23/2011
Last Update Date	:	02/01/2012

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