Basic Information
| Provider Information | |||||||||
| NPI: | 1063739746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S 23RD ST | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824013725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073476165 | ||||||||
| FaxNumber: | 3073476166 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 S 42ND ST STE 514 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026148444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 1194 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1194 | 01 | WY | MENTAL HEALTH PROFESSIONS LICENSING BOARD | OTHER |