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1891491296 NPI number — LYNISHA KELLY-JACKSON PH.D, LP, LSSP, NCS

NPI Number: 1891491296
Health Care Provider/Practitioner: LYNISHA KELLY-JACKSON PH.D, LP, LSSP, NCS

Information about “1891491296” NPI (LYNISHA KELLY-JACKSON PH.D, LP, LSSP, NCS) exists in 1891491296 in HTML format HTML  |  1891491296 in plain Text format TXT  |  1891491296 in PDF (Portable Document Format) PDF  |  1891491296 in an XML format XML  formats.

NPI Number : 1891491296 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1891491296",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "KELLY-JACKSON",
    "FirstName": "LYNISHA",
    "MiddleName": null,
    "NamePrefix": "DR.",
    "NameSuffix": null,
    "Credential": "PH.D, LP, LSSP,  NCS",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "992 MONTGOMERY LN",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "POLK CITY",
    "MailingAddressStateName": "FL",
    "MailingAddressPostalCode": "33868-9097",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "813-638-5836",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "1945 LAKEPOINT DR",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "LEWISVILLE",
    "PracticeLocationAddressStateName": "TX",
    "PracticeLocationAddressPostalCode": "75057",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "813-563-0728",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "02/07/2023",
    "LastUpdateDate": "02/07/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "103TS0200X",
          "TaxonomyName": "School Psychologist",
          "LicenseNumber": "70907",
          "LicenseNumberStateCode": "TX",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "103T00000X",
          "TaxonomyName": "Psychologist",
          "LicenseNumber": "38090",
          "LicenseNumberStateCode": "TX",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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