Basic Information
| Provider Information | |||||||||
| NPI: | 1699141531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | TREMAIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | EDS, MS, NCC, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1115B OPENWOOD ST | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391832533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183412202 | ||||||||
| FaxNumber: | 6015011030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115B OPENWOOD ST | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391832533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183412202 | ||||||||
| FaxNumber: | 6015011030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2015 | ||||||||
| LastUpdateDate: | 08/14/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2016 | MS | Y | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 2016 | MS | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 2016 | MS | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 2016 | MS | N | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | 2016 | MS | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.