MEDICARE: NATHANIEL JACKSON L.P.C.

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	71884	TX

General Provider Information

NPI Number	:	1750546826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHANIEL JACKSON L.P.C.

Provider Business Mailing Address
First Line	:	16135 PRESTON RD
Second Line	:	SUITE #201
City	:	DALLAS
State	:	TX
Zip	:	75248-3599
Country	:	US
Telephone Number	:	972-841-6462
Fax Number	:

Provider Business Practice Location Address
First Line	:	16135 PRESTON RD
Second Line	:	SUITE #201
City	:	DALLAS
State	:	TX
Zip	:	75248-3599
Country	:	US
Telephone Number	:	972-841-6462
Fax Number	:

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

Provider Enumeration Date	:	07/28/2008
Last Update Date	:	08/15/2017

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