Provider Demographics
NPI:1043052707
Name:JACKSON, MICHAEL JORDAIN (LPC-A)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JORDAIN
Last Name:JACKSON
Suffix:
Gender:M
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 1:3000 POLAR LN STE 501
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3073
Mailing Address - Country:US
Mailing Address - Phone:512-400-4321
Mailing Address - Fax:
Practice Address - Street 1:3000 POLAR LN STE 501
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3073
Practice Address - Country:US
Practice Address - Phone:512-400-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91439101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional