Provider Demographics
NPI:1164281085
Name:JACKSON, JOSHUA DEAN
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:DEAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-4612
Mailing Address - Country:US
Mailing Address - Phone:580-512-0053
Mailing Address - Fax:
Practice Address - Street 1:500 MAIN PLACE, 500 N MAIN ST STE 156
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114
Practice Address - Country:US
Practice Address - Phone:316-202-4414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13479104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker