Healthcare Provider Details

I. General information

NPI: 1386030997
Provider Name (Legal Business Name): CRAIG JACKSON B.S., C.A.D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 CLARK ST
DES MOINES IA
50314-1964
US

IV. Provider business mailing address

1409 CLARK ST
DES MOINES IA
50314-1964
US

V. Phone/Fax

Practice location:
  • Phone: 515-643-6500
  • Fax:
Mailing address:
  • Phone: 515-643-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20064
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: