Provider Demographics
NPI:1184443475
Name:JACKSON, KEYANE NIKITA (LPC-A)
Entity type:Individual
Prefix:MS
First Name:KEYANE
Middle Name:NIKITA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2193 GLACIER DR
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-9592
Mailing Address - Country:US
Mailing Address - Phone:214-228-3404
Mailing Address - Fax:
Practice Address - Street 1:1095 BRITTMOORE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-5052
Practice Address - Country:US
Practice Address - Phone:214-228-3404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-04
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96397101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional