Healthcare Provider Details

I. General information

NPI: 1548761265
Provider Name (Legal Business Name): KAYLA M JACKSON LCAT, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 PRINCE ST
ROCHESTER NY
14607-1023
US

IV. Provider business mailing address

350 WESTMINSTER RD
ROCHESTER NY
14607-3233
US

V. Phone/Fax

Practice location:
  • Phone: 585-730-4828
  • Fax:
Mailing address:
  • Phone: 917-843-6105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number000531
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: