Provider Demographics
NPI:1366143273
Name:JACKSON, NICOLE RENEE (LPCC, LMFTC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPCC, LMFTC
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 192
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:CO
Mailing Address - Zip Code:81639-0192
Mailing Address - Country:US
Mailing Address - Phone:765-476-3060
Mailing Address - Fax:
Practice Address - Street 1:825 E SPEER BLVD STE 8
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-3719
Practice Address - Country:US
Practice Address - Phone:765-476-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0014174106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist