Provider Demographics
NPI:1578064861
Name:JACKSON PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:JACKSON PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LSCSW, LCSW
Authorized Official - Phone:816-377-7398
Mailing Address - Street 1:901 KENTUCKY ST STE 306
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2858
Mailing Address - Country:US
Mailing Address - Phone:816-377-7398
Mailing Address - Fax:816-377-7398
Practice Address - Street 1:901 KENTUCKY ST STE 306
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2858
Practice Address - Country:US
Practice Address - Phone:816-377-7398
Practice Address - Fax:816-873-1364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4352261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015021883Medicaid
KS4352Medicaid
MO2015021883OtherBCBS OF KANSAS CITY
KS4352OtherBCBS