Healthcare Provider Details

I. General information

NPI: 1326224288
Provider Name (Legal Business Name): LAURA K JACKSON LCSW; LCDC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3629 CHURCH ST
COVINGTON KY
41015-1430
US

IV. Provider business mailing address

3629 CHURCH ST
COVINGTON KY
41015-1430
US

V. Phone/Fax

Practice location:
  • Phone: 859-581-8974
  • Fax: 859-581-9595
Mailing address:
  • Phone: 859-581-8974
  • Fax: 859-581-9595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 3952
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW-09000933
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDC III- 101140
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: