Provider Demographics
NPI:1801484423
Name:JACKSON, CODY G (MA, LPC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W 10TH AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-6701
Mailing Address - Country:US
Mailing Address - Phone:970-823-2782
Mailing Address - Fax:
Practice Address - Street 1:825 S BROADWAY ST STE 35
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5932
Practice Address - Country:US
Practice Address - Phone:970-823-2782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0016734101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health