Provider Demographics
NPI:1669693453
Name:JACKSON, MARILYN RENEE (LPC-S)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 381465
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75138-1465
Mailing Address - Country:US
Mailing Address - Phone:214-682-0432
Mailing Address - Fax:972-283-2024
Practice Address - Street 1:915 BROOKMERE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-6128
Practice Address - Country:US
Practice Address - Phone:972-502-6660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201027106H00000X
TX63045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist