Healthcare Provider Details

I. General information

NPI: 1184771537
Provider Name (Legal Business Name): KATHLEEN A JACKSON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MEDICAL ARTS AVE NE BLDG 3
ALBUQUERQUE NM
87102-2706
US

IV. Provider business mailing address

1101 MEDICAL ARTS AVE NE BLDG 3
ALBUQUERQUE NM
87102-2706
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-5300
  • Fax: 505-765-1100
Mailing address:
  • Phone: 505-842-5300
  • Fax: 505-765-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1153
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: