Provider Demographics
NPI:1083418057
Name:JACKSON, AMY RUTH (CADC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:RUTH
Last Name:JACKSON
Suffix:
Gender:
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 SKYLINE BLVD APT 142
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-5635
Mailing Address - Country:US
Mailing Address - Phone:775-393-0033
Mailing Address - Fax:
Practice Address - Street 1:5950 ROCK FARM RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-8238
Practice Address - Country:US
Practice Address - Phone:775-393-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV07850-C101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)