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General NPI Number Information
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NPI Number | 1891491296
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Entity Type | Individual
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Provider Name | LYNISHA KELLY-JACKSON PH.D, LP, LSSP, NCS
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Gender | Female
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Dates
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Enumeration Date | 02/07/2023
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Last Update Date | 02/07/2025
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Provider Practice Location Address
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Address Line | 1945 LAKEPOINT DR
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City | LEWISVILLE
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State | TX
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Zip | 75057
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Country | US
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Telephone | 813-563-0728
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Fax |
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Provider Business Mailing Address
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Address Line | 992 MONTGOMERY LN
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City | POLK CITY
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State | FL
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Zip | 33868-9097
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Country | US
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Telephone | 813-638-5836
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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 | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 70907
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 38090
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License Number State | TX
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