Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 12026 | TX |
NPI | 1003264086 |
---|---|
Provider Name | Mr. Adayis Marshay Jackson SR. |
First Address | Austin, TX 78757 |
Second Address | Austin, TX 78757-7043 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2016 |
Last Update Date | 31/05/2016 |