Provider Demographics
NPI:1306126867
Name:JACKSON, KENDRA LORRAINE (LPC)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:LORRAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 RIVA RD STE 142
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7411
Mailing Address - Country:US
Mailing Address - Phone:443-221-7189
Mailing Address - Fax:
Practice Address - Street 1:2525 RIVA RD STE 142
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7411
Practice Address - Country:US
Practice Address - Phone:443-221-7189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP3952101Y00000X
DCLPC14199101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor