Provider Demographics
NPI:1942096987
Name:JACKSON, AMBER MARIE (LCPC)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:
Credentials:LCPC
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:MARIE
Other - Last Name:MOE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:2908 HILLCREST LN
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-3025
Mailing Address - Country:US
Mailing Address - Phone:208-740-0568
Mailing Address - Fax:
Practice Address - Street 1:2908 HILLCREST LN
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-3025
Practice Address - Country:US
Practice Address - Phone:208-740-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4185101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional