Provider Demographics
NPI:1760029086
Name:JACKSON, AMBER R (LPC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:619-695-8010
Mailing Address - Fax:619-695-8010
Practice Address - Street 1:12500 E ILIFF AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1268
Practice Address - Country:US
Practice Address - Phone:970-494-5891
Practice Address - Fax:970-494-5895
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
COLPC.0017796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty