Provider Demographics
NPI:1528492667
Name:JACKSON, ANDREW NOBLE (LPC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:NOBLE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:DREW
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:207 W JACKSON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2355
Mailing Address - Country:US
Mailing Address - Phone:601-896-3079
Mailing Address - Fax:
Practice Address - Street 1:207 W JACKSON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2355
Practice Address - Country:US
Practice Address - Phone:601-982-9551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1799101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional