Provider Demographics
NPI:1316329667
Name:JACKSON, CHAD
Entity type:Individual
Prefix:MR
First Name:CHAD
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
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 22982
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59104-2982
Mailing Address - Country:US
Mailing Address - Phone:406-794-8951
Mailing Address - Fax:
Practice Address - Street 1:3225 1ST AVE N
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-2104
Practice Address - Country:US
Practice Address - Phone:406-794-8951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11415101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1316329667Medicaid