Individual
ILLYA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1518 VAUGHN BLVD, FT WORTH, TX 76105-2307
(214) 515-2079
Mailing address
1518 VAUGHN BLVD, FT WORTH, TX 76105-2307
(214) 515-2079
Taxonomy
Speciality
Code
Description
License number
State
106H00000X
Marriage & Family Therapist
Primary
IACCP0064
CA
Other
Enumeration date
07/02/2015
Last updated
07/02/2015
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