Provider Demographics
NPI:1437357399
Name:JACKSON, ROBERT D (MS, LPC, NCC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 ERINDALE DR STE 112
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6960
Mailing Address - Country:US
Mailing Address - Phone:719-440-4893
Mailing Address - Fax:888-891-4673
Practice Address - Street 1:5525 ERINDALE DR STE 112
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6960
Practice Address - Country:US
Practice Address - Phone:719-440-4893
Practice Address - Fax:888-891-4673
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3187101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3187OtherLICENSED PROFESSIONAL COU
MS142OtherLICENSED PROFESSIONAL COU