MEDICARE: MRS. MARILYN RENEE JACKSON LPC-S

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	106H00000X	Marriage & Family Therapist	201027	TX
2	101YP2500X	Professional Counselor	63045	TX

General Provider Information

NPI Number	:	1669693453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARILYN RENEE JACKSON LPC-S

Provider Business Mailing Address
First Line	:	PO BOX 381465
Second Line	:
City	:	DUNCANVILLE
State	:	TX
Zip	:	75138-1465
Country	:	US
Telephone Number	:	214-682-0432
Fax Number	:	972-283-2024

Provider Business Practice Location Address
First Line	:	915 BROOKMERE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-6128
Country	:	US
Telephone Number	:	972-502-6660
Fax Number	:

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	09/06/2024

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