MEDICARE: MS. SANDRA JONES JACKSON LCPC, PROV LMHC

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	PMH 729	FL
2	101YP2500X	Professional Counselor	LC1622	MD

General Provider Information

NPI Number	:	1669675369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA JONES JACKSON LCPC, PROV LMHC

Provider Business Mailing Address
First Line	:	12003 RUSHWORTH TER
Second Line	:
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-2536
Country	:	US
Telephone Number	:	443-629-2236
Fax Number	:	443-629-2236

Provider Business Practice Location Address
First Line	:	12003 RUSHWORTH TER
Second Line	:
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-2536
Country	:	US
Telephone Number	:	443-629-2236
Fax Number	:

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

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	03/03/2026

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