Provider Demographics
NPI:1659695070
Name:JACKSON, LORI ELLEN (MA, MFT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ELLEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 W 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80214-8014
Mailing Address - Country:US
Mailing Address - Phone:720-232-5908
Mailing Address - Fax:
Practice Address - Street 1:6625 W 26TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80214-8014
Practice Address - Country:US
Practice Address - Phone:720-232-5908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11888171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator