Provider Demographics
NPI:1154626190
Name:JACKSON, DEMETRIA MICHELLE (LMFT)
Entity type:Individual
Prefix:MRS
First Name:DEMETRIA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3866
Mailing Address - Country:US
Mailing Address - Phone:765-288-1110
Mailing Address - Fax:
Practice Address - Street 1:708 W WHITE RIVER BLVD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3866
Practice Address - Country:US
Practice Address - Phone:765-288-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist