Provider Demographics
NPI:1376826693
Name:JACKSON, CAROL A
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 PASEO DEL CANON W
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6743
Mailing Address - Country:US
Mailing Address - Phone:575-779-6138
Mailing Address - Fax:
Practice Address - Street 1:110 PASEO DEL CANON W
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6743
Practice Address - Country:US
Practice Address - Phone:575-779-6138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM090906103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool