| Doctor Name: | MIRANDA JEAN JACKSON |
| NPI Number: | 1750683447 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | LPC.0011343 |
| Business Practice Address: | 820 1st Street Limon, CO - 808281120 |
| Business Phone Number: | 7197752367 |
| Business Fax Number: | 7197752365 |
| Mailing Address: | 820 1st Street, LIMON |
| State: | CO |
| Postal Code: | 808281120 |
| Phone Number: | 7197752367 |
| Fax Number: | 7197752365 |
| NPI Enumeration Date: | 12/01/2010 |
| NPI Last Update Date: | 11/12/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | LPC.0011343 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |