Provider Demographics
NPI:1225923824
Name:LANG, JACKSON (LCMHCA)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:LANG
Suffix:
Gender:M
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 S BRUNS AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-4309
Mailing Address - Country:US
Mailing Address - Phone:781-820-8723
Mailing Address - Fax:
Practice Address - Street 1:447 S SHARON AMITY RD STE 250
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2850
Practice Address - Country:US
Practice Address - Phone:704-264-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health