Provider Demographics
NPI:1104246206
Name:JACKSON, JOSEPH S (LMFT)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 RAWLINS ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1900
Mailing Address - Country:US
Mailing Address - Phone:307-426-4797
Mailing Address - Fax:
Practice Address - Street 1:1011 37TH AVENUE CT
Practice Address - Street 2:STE 201 AND 202
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2562
Practice Address - Country:US
Practice Address - Phone:970-672-4667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0014028101YM0800X
103K00000X
COLMFT.0002235106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst