Provider Demographics
NPI:1225619273
Name:JACKSON, JENNA (LPC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16863 BUFFALO VALLEY PATH
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-7172
Mailing Address - Country:US
Mailing Address - Phone:719-310-8276
Mailing Address - Fax:
Practice Address - Street 1:16863 BUFFALO VALLEY PATH
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-7172
Practice Address - Country:US
Practice Address - Phone:719-310-8276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health