Provider Demographics
NPI:1154556330
Name:JACKSON, SHERRYL ANN (LPC)
Entity type:Individual
Prefix:
First Name:SHERRYL
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SHERRYL
Other - Middle Name:ANN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:118 S 1ST ST STE A
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-2830
Mailing Address - Country:US
Mailing Address - Phone:580-670-0050
Mailing Address - Fax:
Practice Address - Street 1:118 S 1ST ST STE A
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-2830
Practice Address - Country:US
Practice Address - Phone:580-670-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK4806101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator