Provider Demographics
NPI:1215794540
Name:JACKSON, NICOLE PEARL (PLPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:PEARL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S SILVER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-7536
Mailing Address - Country:US
Mailing Address - Phone:573-334-1100
Mailing Address - Fax:573-651-4345
Practice Address - Street 1:402 S SILVER SPRINGS RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7536
Practice Address - Country:US
Practice Address - Phone:573-334-1100
Practice Address - Fax:573-651-4345
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024007661101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health