| Doctor Name: | ROBERTA D JACKSON |
| NPI Number: | 1043232655 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA COUNSELING |
| License Number: | |
| Business Practice Address: | 2316 St Matthews Road Orangeburg, SC - 29118 |
| Business Phone Number: | 8035361571 |
| Business Fax Number: | 8035361463 |
| Mailing Address: | 2319 St Matthews Road, ORANGEBURG |
| State: | SC |
| Postal Code: | 29118 |
| Phone Number: | 8035361571 |
| Fax Number: | 8035361463 |
| NPI Enumeration Date: | 07/24/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |