Healthcare Provider Details

I. General information

NPI: 1750683447
Provider Name (Legal Business Name): MIRANDA JEAN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55981 E COLFAX AVE
STRASBURG CO
80136-8014
US

IV. Provider business mailing address

3205 N ACADEMY BLVD SUITE 130
COLORADO SPRINGS CO
80917-5147
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5700
  • Fax: 719-344-7817
Mailing address:
  • Phone: 719-632-5700
  • Fax: 719-344-7817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0011343
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: