Provider Demographics
NPI:1366895427
Name:POWELL, JACKIE (MAC, LISAC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:MAC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6262 E BROADWAY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6101
Mailing Address - Country:US
Mailing Address - Phone:480-664-4053
Mailing Address - Fax:480-452-0883
Practice Address - Street 1:6262 E BROADWAY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6101
Practice Address - Country:US
Practice Address - Phone:480-664-4053
Practice Address - Fax:480-452-0883
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-15108101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)