Provider Demographics
NPI:1891220935
Name:JACKSON-WEBB, MARY YVETTE (LCSW,LAC,MAC,CIMHP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:YVETTE
Last Name:JACKSON-WEBB
Suffix:
Gender:F
Credentials:LCSW,LAC,MAC,CIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 N. ACADEMY BLVD.
Mailing Address - Street 2:SUITE #206
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5328
Mailing Address - Country:US
Mailing Address - Phone:719-297-3499
Mailing Address - Fax:
Practice Address - Street 1:2790 N ACADEMY BLVD BLDG SUITE206
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5337
Practice Address - Country:US
Practice Address - Phone:719-297-3499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2023-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1914101YA0400X
CO133N00000X
COCSW099273881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No133N00000XDietary & Nutritional Service ProvidersNutritionist