Provider Demographics
NPI:1750683447
Name:JACKSON, MIRANDA JEAN
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5147
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-344-7817
Practice Address - Street 1:55981 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:STRASBURG
Practice Address - State:CO
Practice Address - Zip Code:80136-8014
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-344-7817
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0011343101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28034546Medicaid