Provider Demographics
NPI:1386030997
Name:JACKSON, CRAIG (BS, CADC)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BS, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1964
Mailing Address - Country:US
Mailing Address - Phone:515-643-6500
Mailing Address - Fax:
Practice Address - Street 1:1409 CLARK ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1964
Practice Address - Country:US
Practice Address - Phone:515-643-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IA20064101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA20064OtherIOWA BOARD OF CERTIFICATION