Provider Demographics
NPI:1487162608
Name:JACKSON, RUBY J (DPC, LPC-S, NCC)
Entity type:Individual
Prefix:DR
First Name:RUBY
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPC, LPC-S, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 AZALEA CT
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7952
Mailing Address - Country:US
Mailing Address - Phone:601-201-4134
Mailing Address - Fax:
Practice Address - Street 1:302 AZALEA CT
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7952
Practice Address - Country:US
Practice Address - Phone:601-201-4134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1306101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty