Provider Demographics
NPI:1083233316
Name:JACKSON, AHRIELLE
Entity type:Individual
Prefix:
First Name:AHRIELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SMITH ST # 61070
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-2714
Mailing Address - Country:US
Mailing Address - Phone:817-369-5528
Mailing Address - Fax:
Practice Address - Street 1:5341 THRESHING DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-8147
Practice Address - Country:US
Practice Address - Phone:910-545-4189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68117104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker