Provider Demographics
NPI:1902288764
Name:JACKSON, CARMELLA (LPC)
Entity Type:Individual
Prefix:
First Name:CARMELLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7973 THOURON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2520
Mailing Address - Country:US
Mailing Address - Phone:267-307-9700
Mailing Address - Fax:
Practice Address - Street 1:261 OLD YORK RD STE 709
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3728
Practice Address - Country:US
Practice Address - Phone:215-690-1004
Practice Address - Fax:267-907-1120
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YA0400X
PAPC007622101YM0800X
PA8062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)