Provider Demographics
NPI:1073654034
Name:JACKSON, LYNDELL (LCPC)
Entity Type:Individual
Prefix:MS
First Name:LYNDELL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4343
Mailing Address - Country:US
Mailing Address - Phone:208-880-6127
Mailing Address - Fax:208-455-6244
Practice Address - Street 1:2020 BLAINE ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4343
Practice Address - Country:US
Practice Address - Phone:208-880-6127
Practice Address - Fax:208-455-6244
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ1109OtherBLUE CROSS
ID000010016363OtherREGENCE BLUE SHIELD