Provider Demographics
NPI:1215713375
Name:JACKSON, JAILYN (LCMHC-A)
Entity type:Individual
Prefix:
First Name:JAILYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N MAIN ST STE 304
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27253-2853
Mailing Address - Country:US
Mailing Address - Phone:336-265-6723
Mailing Address - Fax:
Practice Address - Street 1:200 N MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:NC
Practice Address - Zip Code:27253-2853
Practice Address - Country:US
Practice Address - Phone:336-265-6723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18729101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health