Provider Demographics
NPI:1386937845
Name:CARLSON, JACKLYN (LCPC)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:CARLSON
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 1:2748 CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-3752
Mailing Address - Country:US
Mailing Address - Phone:406-788-3068
Mailing Address - Fax:
Practice Address - Street 1:1601 2ND AVE N
Practice Address - Street 2:#614
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3259
Practice Address - Country:US
Practice Address - Phone:406-788-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1356101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional