Provider Demographics
NPI:1992276810
Name:JACKSON, TERRONDA LANAE (MA, LPCA)
Entity type:Individual
Prefix:MRS
First Name:TERRONDA
Middle Name:LANAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HUNTERS RUN DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-9206
Mailing Address - Country:US
Mailing Address - Phone:302-265-5993
Mailing Address - Fax:
Practice Address - Street 1:140 HUNTERS RUN DR
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-9206
Practice Address - Country:US
Practice Address - Phone:803-814-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6574101YM0800X, 101YP1600X, 101YP2500X, 251S00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6574OtherLPCA
1045081474OtherTRICARE PRIME