MEDICARE: MRS. TIERRA JACKSON LPCA, LMFTA, RMFTI

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	106H00000X	Marriage & Family Therapist	IMT2200	FL
2	106H00000X	Marriage & Family Therapist	9096A	NC
3	101YP2500X	Professional Counselor	A10704	NC

General Provider Information

NPI Number	:	1225440548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIERRA JACKSON LPCA, LMFTA, RMFTI

Provider Business Mailing Address
First Line	:	910 UTE TRL
Second Line	:
City	:	PATRICK AFB
State	:	FL
Zip	:	32925-3160
Country	:	US
Telephone Number	:	828-994-7718
Fax Number	:

Provider Business Practice Location Address
First Line	:	4680 LIPSCOMB ST NE
Second Line	:	SUITE 10A
City	:	PALM BAY
State	:	FL
Zip	:	32905-2984
Country	:	US
Telephone Number	:	321-433-3570
Fax Number	:

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

Provider Enumeration Date	:	05/21/2014
Last Update Date	:	12/17/2014

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