Provider Demographics
NPI:1063739746
Name:JACKSON, STEVEN WAYNE (LPC)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-3725
Mailing Address - Country:US
Mailing Address - Phone:307-347-6165
Mailing Address - Fax:307-347-6166
Practice Address - Street 1:1941 S 42ND ST STE 514
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105
Practice Address - Country:US
Practice Address - Phone:402-614-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WY1194101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1194OtherMENTAL HEALTH PROFESSIONS LICENSING BOARD