Provider Demographics
NPI:1699141531
Name:JACKSON, LEON TREMAIN (EDS, MS, NCC, LPC)
Entity type:Individual
Prefix:MR
First Name:LEON
Middle Name:TREMAIN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:EDS, MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115B OPENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2533
Mailing Address - Country:US
Mailing Address - Phone:318-341-2202
Mailing Address - Fax:601-501-1030
Practice Address - Street 1:1115B OPENWOOD ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2533
Practice Address - Country:US
Practice Address - Phone:318-341-2202
Practice Address - Fax:601-501-1030
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2016101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist