Provider Demographics
NPI:1194417253
Name:RICHARDSON, JACKI ELIZABETH (LCPC)
Entity type:Individual
Prefix:
First Name:JACKI
Middle Name:ELIZABETH
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24337
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-4337
Mailing Address - Country:US
Mailing Address - Phone:406-200-8914
Mailing Address - Fax:
Practice Address - Street 1:1811 S ALMA SCHOOL RD STE 250
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3042
Practice Address - Country:US
Practice Address - Phone:406-200-8914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-58305101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health