Provider Demographics
NPI:1366199788
Name:JACKSON, MARCIA LORETTA (LPC)
Entity type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:LORETTA
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 1:5102 PALMER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-2124
Mailing Address - Country:US
Mailing Address - Phone:719-271-4006
Mailing Address - Fax:
Practice Address - Street 1:3141 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4094
Practice Address - Country:US
Practice Address - Phone:719-327-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-05
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0005441101YA0400X
COLPC.0016164101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)