MEDICARE: CRYSTAL JACKSON LCASA

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
2	101YM0800X	Mental Health Counselor	3432-A	NC

General Provider Information

NPI Number	:	1336560861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL JACKSON LCASA

Provider Business Mailing Address
First Line	:	9008 BROAD RIDGE CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5199
Country	:	US
Telephone Number	:	336-254-8677
Fax Number	:

Provider Business Practice Location Address
First Line	:	9008 BROAD RIDGE CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5199
Country	:	US
Telephone Number	:	336-254-8677
Fax Number	:

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

Provider Enumeration Date	:	12/31/2013
Last Update Date	:	09/26/2021

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