Basic Information
| Provider Information | |||||||||
| NPI: | 1194055087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | JO-JIVIDEN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LIMHP, LMHP, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 917 W 21ST ST | ||||||||
| Address2: | PO BOX 355 | ||||||||
| City: | SOUTH SIOUX CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687762652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024943337 | ||||||||
| FaxNumber: | 4024943356 | ||||||||
| Practice Location | |||||||||
| Address1: | 917 W 21ST ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH SIOUX CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687762652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024943337 | ||||||||
| FaxNumber: | 4024943356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2009 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 8988 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 1904 | NE | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 3842 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 919 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.