Basic Information
| Provider Information | |||||||||
| NPI: | 1063548709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | KATHRYN | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4312 CARLISLE BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053233785 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3025 FLORIDA ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871102614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054176744 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0124141 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.