Provider Demographics
NPI:1215343009
Name:JACKSON, DEIRDRE RENEE' (PHD LCMHCS LPC NCC)
Entity type:Individual
Prefix:DR
First Name:DEIRDRE
Middle Name:RENEE'
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD LCMHCS LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 SPICER DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-2120
Mailing Address - Country:US
Mailing Address - Phone:615-473-5152
Mailing Address - Fax:
Practice Address - Street 1:1059 SPICER DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-2120
Practice Address - Country:US
Practice Address - Phone:615-473-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS12958101YM0800X
TN1744101YP2500X
TX77544101YP2500X
LA5911101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health