Provider Demographics
NPI:1992350151
Name:JACKSON, TANDY (LPC-MHSP)
Entity type:Individual
Prefix:
First Name:TANDY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 VILLA PL
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-3019
Mailing Address - Country:US
Mailing Address - Phone:720-432-6292
Mailing Address - Fax:
Practice Address - Street 1:8931 HURON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-6806
Practice Address - Country:US
Practice Address - Phone:303-853-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5165101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health