Provider Demographics
NPI:1427280668
Name:JACKSON, DAVID W (LPCC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 RENCHER ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5858
Mailing Address - Country:US
Mailing Address - Phone:575-769-2142
Mailing Address - Fax:575-769-2161
Practice Address - Street 1:919 RENCHER ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5858
Practice Address - Country:US
Practice Address - Phone:575-769-2142
Practice Address - Fax:575-769-2161
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0089191101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04937261Medicaid