Basic Information
| Provider Information | |||||||||
| NPI: | 1366199788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | LORETTA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5102 PALMER PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809152124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192714006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3141 CENTENNIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809074094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193275660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2022 | ||||||||
| LastUpdateDate: | 03/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ACC.0005441 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LPC.0016164 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.