Provider Demographics
NPI:1487990149
Name:JACKSON, LAURIE (LCSW)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 IMPERIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3479
Mailing Address - Country:US
Mailing Address - Phone:156-185-0296
Mailing Address - Fax:615-757-3152
Practice Address - Street 1:107 IMPERIAL BLVD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3479
Practice Address - Country:US
Practice Address - Phone:615-618-5029
Practice Address - Fax:615-757-3152
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9553101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health