Healthcare Provider Details

I. General information

NPI: 1932814456
Provider Name (Legal Business Name): MRS. KATY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 CHARRING CROSS DR S
WESTERVILLE OH
43081-2862
US

IV. Provider business mailing address

171 CHARRING CROSS DR S
WESTERVILLE OH
43081-2862
US

V. Phone/Fax

Practice location:
  • Phone: 614-890-8262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: