Provider Demographics
NPI:1992024228
Name:JACKSON, SARA LAFAWN (MS LPC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LAFAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-3802
Mailing Address - Country:US
Mailing Address - Phone:580-649-8355
Mailing Address - Fax:580-649-8355
Practice Address - Street 1:120 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3802
Practice Address - Country:US
Practice Address - Phone:580-649-8355
Practice Address - Fax:580-379-4010
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK4704101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor