Healthcare Provider Details

I. General information

NPI: 1184009367
Provider Name (Legal Business Name): MARY JACKSON LCPC, LCAC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2148 BROADWAY STE C5
GRAND JUNCTION CO
81507-1098
US

IV. Provider business mailing address

2148 BROADWAY STE C5
GRAND JUNCTION CO
81507-1098
US

V. Phone/Fax

Practice location:
  • Phone: 970-230-3559
  • Fax:
Mailing address:
  • Phone: 970-230-3559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2738
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0730
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: