Provider Demographics
NPI:1518735786
Name:JACKSON, BROOK (LPC)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 NW ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-3163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PURE LIFE 1
Practice Address - Street 2:
Practice Address - City:TINAMASTES
Practice Address - State:PEREZ ZELEDON
Practice Address - Zip Code:11902
Practice Address - Country:CR
Practice Address - Phone:503-358-4293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC7636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional