Provider Demographics
NPI:1386915494
Name:JACKSON, EMILY NANETTE (LPC, NCC, CSOTS)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:NANETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC, NCC, CSOTS
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 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2738
Mailing Address - Country:US
Mailing Address - Phone:706-887-5787
Mailing Address - Fax:706-780-5402
Practice Address - Street 1:200 N LEWIS ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2738
Practice Address - Country:US
Practice Address - Phone:706-887-5787
Practice Address - Fax:706-780-5402
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006931101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003215089AMedicaid