Provider Demographics
NPI:1811377161
Name:JACKSON, JENNIFER R (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 W BETHANY HOME RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1939
Mailing Address - Country:US
Mailing Address - Phone:602-774-4745
Mailing Address - Fax:
Practice Address - Street 1:2102 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1935
Practice Address - Country:US
Practice Address - Phone:602-774-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-15286101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health