Provider Demographics
NPI:1720838535
Name:JACKSON, LAURA GAIL (ALC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GAIL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 CLUBVIEW ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1625
Mailing Address - Country:US
Mailing Address - Phone:334-354-5361
Mailing Address - Fax:334-460-9814
Practice Address - Street 1:2046 CLUBVIEW ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1625
Practice Address - Country:US
Practice Address - Phone:334-322-4437
Practice Address - Fax:334-460-9814
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04727101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor