MEDICARE: TISHARA A. JACKSON ED.D, LCDC, CSC

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	15299	TX

General Provider Information

NPI Number	:	1477319119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TISHARA A. JACKSON ED.D, LCDC, CSC

Provider Business Mailing Address
First Line	:	5613 MOUNT STORM WAY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-4438
Country	:	US
Telephone Number	:	773-996-3797
Fax Number	:

Provider Business Practice Location Address
First Line	:	8201 SOUTHBROOK CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-5332
Country	:	US
Telephone Number	:	773-996-3797
Fax Number	:

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

Provider Enumeration Date	:	02/21/2024
Last Update Date	:	04/02/2025

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