Provider Demographics
NPI:1548310048
Name:JACKSON, ELAINE WHITE (LPCC,IIMFT)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:WHITE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPCC,IIMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14843 W SPRAGUE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-1754
Mailing Address - Country:US
Mailing Address - Phone:440-234-9955
Mailing Address - Fax:440-234-5994
Practice Address - Street 1:14843 W SPRAGUE RD
Practice Address - Street 2:SUITE A
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-1754
Practice Address - Country:US
Practice Address - Phone:440-234-9955
Practice Address - Fax:440-234-5994
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0001726101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE0001726OtherLPCC
OHF0000082OtherIMFT