Provider Demographics
NPI:1700490059
Name:JACKSON, LARISSA M (PLADC)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3327 N 163RD PLZ APT 304
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-2149
Mailing Address - Country:US
Mailing Address - Phone:402-510-0668
Mailing Address - Fax:
Practice Address - Street 1:8502 MORMON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-1929
Practice Address - Country:US
Practice Address - Phone:402-455-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1781101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)