Provider Demographics
NPI:1104596253
Name:JACKSON, HEATHER LOUISE (LPC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LOUISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5309 WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-5252
Mailing Address - Country:US
Mailing Address - Phone:706-809-4050
Mailing Address - Fax:
Practice Address - Street 1:4080 MCGINNIS FERRY RD STE 1304
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3951
Practice Address - Country:US
Practice Address - Phone:678-740-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-19
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014188101YM0800X
GAAPC007675101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health