Healthcare Provider Details

I. General information

NPI: 1578928305
Provider Name (Legal Business Name): JA'WANN JACKSON MA, NCC, PLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11959 E KANSAS DR APT D
AURORA CO
80012-4207
US

IV. Provider business mailing address

11959 E KANSAS DR APT D
AURORA CO
80012-4207
US

V. Phone/Fax

Practice location:
  • Phone: 580-695-2680
  • Fax: 712-213-2175
Mailing address:
  • Phone: 580-695-2680
  • Fax: 712-213-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0001384
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: