Provider Demographics
NPI:1609553114
Name:JACKSON, KATHIE JO (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:JO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:SUE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:736 CABOT DR # 80516
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-2689
Mailing Address - Country:US
Mailing Address - Phone:720-299-6747
Mailing Address - Fax:
Practice Address - Street 1:736 CABOT DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516-2689
Practice Address - Country:US
Practice Address - Phone:720-299-6747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW009899371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty