Provider Demographics
NPI:1801059282
Name:JACKSON, CLARISSE L
Entity type:Individual
Prefix:MS
First Name:CLARISSE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6240 S MAIN ST
Mailing Address - Street 2:SUITE 265
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-5376
Mailing Address - Country:US
Mailing Address - Phone:720-274-5296
Mailing Address - Fax:720-274-5267
Practice Address - Street 1:6240 S MAIN ST
Practice Address - Street 2:SUITE 265
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-5376
Practice Address - Country:US
Practice Address - Phone:720-274-5296
Practice Address - Fax:720-274-5267
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.006033101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional