Provider Demographics
NPI:1215484860
Name:JACKSON FAMILY THERAPY AND COUNSELING
Entity type:Organization
Organization Name:JACKSON FAMILY THERAPY AND COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:II
Authorized Official - Credentials:PHD
Authorized Official - Phone:334-707-2634
Mailing Address - Street 1:2117 HAMBY COVE DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-6493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2117 HAMBY COVE DR, NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102
Practice Address - Country:US
Practice Address - Phone:334-707-2634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health