Provider Demographics
NPI:1962651703
Name:JACKSON, LETITIA (LPC)
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:
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 1:13731 E RICE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-1077
Mailing Address - Country:US
Mailing Address - Phone:720-949-1707
Mailing Address - Fax:206-392-3177
Practice Address - Street 1:13731 E RICE PL STE 200
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1077
Practice Address - Country:US
Practice Address - Phone:720-949-1707
Practice Address - Fax:206-392-3177
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5045OtherLPC LICENSE