Provider Demographics
NPI:1902069214
Name:JACKSON, REBECCA JO (LPC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JO
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCMHC
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-0504
Mailing Address - Country:US
Mailing Address - Phone:864-610-0658
Mailing Address - Fax:
Practice Address - Street 1:25 SPRINGDALE DR
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-2159
Practice Address - Country:US
Practice Address - Phone:864-610-0658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8204101YP2500X
NC17497101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC262898892OtherEIN