Provider Demographics
NPI:1265948194
Name:JACKSON, PAMELA ANN (CRADC)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 NEW CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-1364
Mailing Address - Country:US
Mailing Address - Phone:816-813-7533
Mailing Address - Fax:
Practice Address - Street 1:106 S INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-2348
Practice Address - Country:US
Practice Address - Phone:816-813-7533
Practice Address - Fax:816-813-7533
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO9827101YA0400X
106H00000X
MO7780101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist