MEDICARE: CHRISTIAN NICOLE RECORD-JACKSON PSY 0810008030

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	101YP2500X	Professional Counselor	105956	CA
2	103TC0700X	Clinical Psychologist	0810008030	VA

General Provider Information

NPI Number	:	1407344518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTIAN NICOLE RECORD-JACKSON PSY 0810008030

Provider Business Mailing Address
First Line	:	3905 26TH ST
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-9383
Country	:	US
Telephone Number	:	831-239-8364
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 WILFORD HALL LOOP
Second Line	:
City	:	JBSA LACKLAND
State	:	TX
Zip	:	78236-5638
Country	:	US
Telephone Number	:	210-292-6255
Fax Number	:	210-292-7934

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

Provider Enumeration Date	:	04/24/2018
Last Update Date	:	05/18/2026

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