Provider Demographics
NPI:1083908180
Name:JACKSI, SHARON S (PHD,)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:S
Last Name:JACKSI
Suffix:
Gender:F
Credentials:PHD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 TIARA DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-8717
Mailing Address - Country:US
Mailing Address - Phone:720-272-1066
Mailing Address - Fax:
Practice Address - Street 1:486 TIARA DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81507-8717
Practice Address - Country:US
Practice Address - Phone:720-272-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO769103TB0200X, 103TC0700X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical