Healthcare Provider Details

I. General information

NPI: 1154846533
Provider Name (Legal Business Name): JACKSON PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 KENTUCKY ST STE 306
LAWRENCE KS
66044-2858
US

IV. Provider business mailing address

901 KENTUCKY ST STE 306
LAWRENCE KS
66044-2858
US

V. Phone/Fax

Practice location:
  • Phone: 816-377-7398
  • Fax: 816-873-1364
Mailing address:
  • Phone: 816-377-7398
  • Fax: 816-873-1364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: REGINALD C. JACKSON
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential: LSCSW, LCSW
Phone: 816-377-7398