Healthcare Provider Details

I. General information

NPI: 1043270093
Provider Name (Legal Business Name): JILL ALANA JACKSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 COTTONWOOD RD
CRESTON IA
50801-1911
US

IV. Provider business mailing address

709 COTTONWOOD RD
CRESTON IA
50801-1911
US

V. Phone/Fax

Practice location:
  • Phone: 641-278-1095
  • Fax: 641-278-1095
Mailing address:
  • Phone: 641-278-1095
  • Fax: 641-278-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number00738
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number00738
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00738
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: