Provider Demographics
NPI:1487980652
Name:JACKSON, CAROL DENISE (ACADC)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 17TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1418
Mailing Address - Country:US
Mailing Address - Phone:515-279-0335
Mailing Address - Fax:
Practice Address - Street 1:1522 17TH STREET
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-0000
Practice Address - Country:US
Practice Address - Phone:515-279-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA92151101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAX000202269Medicaid