Provider Demographics
NPI:1235206491
Name:JACKSON, TONY L (PLMHP)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8260 READ ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-1428
Mailing Address - Country:US
Mailing Address - Phone:402-690-1880
Mailing Address - Fax:
Practice Address - Street 1:1111 S 119TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-1601
Practice Address - Country:US
Practice Address - Phone:402-690-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7989101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health