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General NPI Number Information
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NPI Number | 1871141457
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Entity Type | Individual
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Provider Name | PATRICK DIOR JACKSON
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Gender | Male
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Dates
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Enumeration Date | 08/28/2019
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Last Update Date | 08/28/2019
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Provider Practice Location Address
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Address Line | 5111 S 3RD ST
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City | LOUISVILLE
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State | KY
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Zip | 40214-2601
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Country | US
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Telephone | 502-690-1511
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Fax |
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Provider Business Mailing Address
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Address Line | 811 STONEBENCH CIR
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City | JEFFERSONVLLE
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State | IN
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Zip | 47130-4220
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Country | US
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Telephone | 812-557-5365
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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 | 101YS0200X
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Taxonomy Name | School Counselor
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License Number | 201114318
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License Number State | KY
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