MEDICARE: LEE E JACKSON

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	13217	TX

General Provider Information

NPI Number	:	1891368668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEE E JACKSON

Provider Business Mailing Address
First Line	:	1229 E PLEASANT RUN RD STE 200
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-4214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1229 E PLEASANT RUN RD STE 200
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-4214
Country	:	US
Telephone Number	:	972-226-4261
Fax Number	:

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

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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Directions to “ LEE E JACKSON ” Practice Location

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