Healthcare Provider Details

I. General information

NPI: 1629991674
Provider Name (Legal Business Name): KATHERINE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 N ELISEO FELIX JR WAY
AVONDALE AZ
85323-1216
US

IV. Provider business mailing address

1481 N ELISEO FELIX JR WAY
AVONDALE AZ
85323-1216
US

V. Phone/Fax

Practice location:
  • Phone: 623-932-7752
  • Fax:
Mailing address:
  • Phone: 623-932-7752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4568043
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: