Provider Demographics
NPI:1194267476
Name:JACKSON, ANGELA DECARLA (PHD, LCPC, LMHC)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:DECARLA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD, LCPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 N EDDY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1478
Mailing Address - Country:US
Mailing Address - Phone:312-798-9755
Mailing Address - Fax:
Practice Address - Street 1:1251 N EDDY ST STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1478
Practice Address - Country:US
Practice Address - Phone:312-798-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011258101YM0800X
OHC.1400533101YP2500X
IL178.011168101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional