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General NPI Number Information
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NPI Number | 1124212972
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Entity Type | Individual
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Provider Name | JACKS X GILLES PSY.D., LP
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Gender |
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Dates
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Enumeration Date | 09/04/2007
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 633 BAXTER AVE
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City | LOUISVILLE
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State | KY
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Zip | 40204-1157
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Country | US
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Telephone | 502-309-2408
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Fax |
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Provider Business Mailing Address
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Address Line | 633 BAXTER AVE
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City | LOUISVILLE
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State | KY
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Zip | 40204-1157
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Country | US
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Telephone | 502-309-2403
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1745
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2012-12
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 129842
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License Number State | KY
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