Provider Demographics
NPI:1538821095
Name:JACKSON, ASIA K (LGPC)
Entity type:Individual
Prefix:
First Name:ASIA
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DUNHAVEN PL APT 1C
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-7552
Mailing Address - Country:US
Mailing Address - Phone:443-619-8186
Mailing Address - Fax:
Practice Address - Street 1:9649 BELAIR RD STE 104
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1117
Practice Address - Country:US
Practice Address - Phone:410-529-1309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11866101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional