Provider Demographics
NPI:1912500554
Name:JACKSON, RICHARD BRENDAN (LPC, LMAC-T)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:BRENDAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC, LMAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 RICHARDS DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66216-1724
Mailing Address - Country:US
Mailing Address - Phone:913-248-1943
Mailing Address - Fax:
Practice Address - Street 1:6221 RICHARDS DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66216-1724
Practice Address - Country:US
Practice Address - Phone:913-248-1943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS00906-T101YA0400X
KS03696101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)