Provider Demographics
NPI:1184009367
Name:JACKSON, MARY (LPC, TLAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC, TLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 WAKARUSA DR
Mailing Address - Street 2:STE E222
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3882
Mailing Address - Country:US
Mailing Address - Phone:785-843-5483
Mailing Address - Fax:785-841-5433
Practice Address - Street 1:1201 WAKARUSA DR
Practice Address - Street 2:STE E222
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3882
Practice Address - Country:US
Practice Address - Phone:785-843-5483
Practice Address - Fax:785-841-5433
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0730101YA0400X
KS2738101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)