Provider Demographics
NPI:1578900510
Name:JACKSON, TARA M (MA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 MAIN AVE STE 248
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5077
Mailing Address - Country:US
Mailing Address - Phone:970-799-0765
Mailing Address - Fax:
Practice Address - Street 1:1911 MAIN AVE STE 248
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5077
Practice Address - Country:US
Practice Address - Phone:970-799-0765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0011985101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional