Provider Demographics
NPI:1497787154
Name:JACKSON-COLBURN, JENNIFER R (LSCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:JACKSON-COLBURN
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-0677
Mailing Address - Country:US
Mailing Address - Phone:913-557-9096
Mailing Address - Fax:913-294-9247
Practice Address - Street 1:25955 W 327TH ST
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-4920
Practice Address - Country:US
Practice Address - Phone:913-557-9096
Practice Address - Fax:913-294-9247
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 37331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200439270BMedicaid
KS856986OtherMEDICARE