Healthcare Provider Details

I. General information

NPI: 1427047380
Provider Name (Legal Business Name): KELLY ELAINE JACKSON MS, CGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CHESTNUT ST
LOUISVILLE KY
40202
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-0850
  • Fax: 502-588-0721
Mailing address:
  • Phone: 502-588-0850
  • Fax: 502-588-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC008
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: