Individual
MRS. TERRONDA LANAE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MA, LPCA
Contact information
Practice address
140 HUNTERS RUN DR, BLYTHEWOOD, SC 29016-9206
(803) 814-7115
Mailing address
140 HUNTERS RUN DR, BLYTHEWOOD, SC 29016-9206
(302) 265-5993
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
6574
SC
101YM0800X
Mental Health Counselor
6574
SC
101YP1600X
Pastoral Counselor
6574
SC
101YP2500X
Professional Counselor
6574
SC
251S00000X
Community/Behavioral Health Agency
6574
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1045081474
TRICARE PRIME
—
01
—
6574
LPCA
SC
Enumeration date
12/17/2018
Last updated
12/17/2018
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