MEDICARE: CHARLES RONALD JACKSON JR.

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	101YM0800X	Mental Health Counselor	10276273942	MD

General Provider Information

NPI Number	:	1245186972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES RONALD JACKSON JR.

Provider Business Mailing Address
First Line	:	2611 LUANA DR APT 101
Second Line	:
City	:	DISTRICT HEIGHTS
State	:	MD
Zip	:	20747-3381
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1835 24TH ST NE APT 202
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20002-1926
Country	:	US
Telephone Number	:	202-905-4769
Fax Number	:

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

Provider Enumeration Date	:	03/05/2026
Last Update Date	:	03/05/2026

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