Provider Demographics
NPI:1912230129
Name:JACKSON, SUSAN H (LPC, CAC II)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC, CAC II
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:HOLLY
Other - Last Name:BESSON JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6807
Mailing Address - Country:US
Mailing Address - Phone:803-335-1219
Mailing Address - Fax:803-335-1689
Practice Address - Street 1:410 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 2300
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6807
Practice Address - Country:US
Practice Address - Phone:803-335-1219
Practice Address - Fax:803-335-1689
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002609101YP2500X
SC2477101YP2500X
GA002609101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional