Provider Demographics
NPI:1902352412
Name:JACKSON, DIANA SUE (LMHC, CADC)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 HICKORY HILL LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-3740
Mailing Address - Country:US
Mailing Address - Phone:319-213-3775
Mailing Address - Fax:
Practice Address - Street 1:1744 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2306
Practice Address - Country:US
Practice Address - Phone:319-366-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14116101YA0400X
IA079713101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)