Provider Demographics
NPI:1396917266
Name:JACKSON, DIXIE L (LPC)
Entity type:Individual
Prefix:
First Name:DIXIE
Middle Name:L
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 1:800 E BLACKHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-1698
Mailing Address - Country:US
Mailing Address - Phone:608-326-0808
Mailing Address - Fax:608-326-0810
Practice Address - Street 1:800 E BLACKHAWK AVE
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-1698
Practice Address - Country:US
Practice Address - Phone:608-326-0808
Practice Address - Fax:608-326-0810
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3842101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43713500Medicaid