Provider Demographics
NPI:1295918530
Name:JACKSON, CHRISTOPHER LADD (MC, LPC, LISAC, NCGC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:LADD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MC, LPC, LISAC, NCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7164
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374
Mailing Address - Country:US
Mailing Address - Phone:602-614-5926
Mailing Address - Fax:623-583-3888
Practice Address - Street 1:12301 W BELL RD STE A102
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-9707
Practice Address - Country:US
Practice Address - Phone:602-614-5926
Practice Address - Fax:623-583-3888
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11483101YA0400X
AZLPC-12267101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)