1073383402 NPI number — CARMELLIA KAY JACKSON CSW, MFT-ASSOCIATE

Table of content: CARMELLIA KAY JACKSON CSW, MFT-ASSOCIATE (NPI 1073383402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073383402 NPI number — CARMELLIA KAY JACKSON CSW, MFT-ASSOCIATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
CARMELLIA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CSW, MFT-ASSOCIATE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073383402
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 TAMARACK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSONVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47130-5431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-802-3779
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 RACE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42501-2156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-509-9772
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  276506 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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