Provider Demographics
NPI:1871742791
Name:JACKSON, CHARLES WAYNE (LPC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16320 HUEBNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-1690
Mailing Address - Country:US
Mailing Address - Phone:210-425-5047
Mailing Address - Fax:830-215-0223
Practice Address - Street 1:16320 HUEBNER RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78248-1690
Practice Address - Country:US
Practice Address - Phone:210-425-5047
Practice Address - Fax:830-215-0223
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63795101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional