Provider Demographics
NPI:1326082322
Name:JACKSON-ISTAS, PATRICIA L (LSCSW, LCAC)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:L
Last Name:JACKSON-ISTAS
Suffix:
Gender:F
Credentials:LSCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 TIMBERWICK PL
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-3054
Mailing Address - Country:US
Mailing Address - Phone:785-313-0900
Mailing Address - Fax:785-537-8028
Practice Address - Street 1:210 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CONCORDIA
Practice Address - State:KS
Practice Address - Zip Code:66901-5200
Practice Address - Country:US
Practice Address - Phone:785-243-8900
Practice Address - Fax:785-243-8933
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS468101YA0400X
KS35871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)