Provider Demographics
NPI:1114221991
Name:JENNIFER JACKSON, LPC, PLLC
Entity Type:Organization
Organization Name:JENNIFER JACKSON, LPC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:605-342-8082
Mailing Address - Street 1:1301 W OMAHA ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2447
Mailing Address - Country:US
Mailing Address - Phone:605-342-8082
Mailing Address - Fax:605-341-3563
Practice Address - Street 1:1301 W OMAHA ST
Practice Address - Street 2:SUITE 209
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2447
Practice Address - Country:US
Practice Address - Phone:605-342-8082
Practice Address - Fax:605-341-3563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC7130101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty