Provider Demographics
NPI:1275223778
Name:JACKSON, SPENCER (PLMHP)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 S 56TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-2219
Mailing Address - Country:US
Mailing Address - Phone:712-560-5835
Mailing Address - Fax:
Practice Address - Street 1:8601 W DODGE RD STE 106
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3405
Practice Address - Country:US
Practice Address - Phone:402-575-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13334101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor