Provider Demographics
NPI:1003366329
Name:JACKSON, JACOB JERRY (PHD, LMHC, CADC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JERRY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD, LMHC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-2559
Mailing Address - Country:US
Mailing Address - Phone:712-499-0207
Mailing Address - Fax:
Practice Address - Street 1:180 10TH ST SE STE 201
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2557
Practice Address - Country:US
Practice Address - Phone:712-546-4624
Practice Address - Fax:712-546-9395
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15081101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)