MEDICARE: MS. KIMBERLY JACKOWSKI LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	102L00000X	Psychoanalyst
4	101YP2500X	Professional Counselor	LAC-16779	AZ
5	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1407444771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY JACKOWSKI LAC

Provider Business Mailing Address
First Line	:	152 N POWER RD STE 2
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-8436
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	152 N POWER RD STE 2
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-8436
Country	:	US
Telephone Number	:	480-542-2525
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2021
Last Update Date	:	01/04/2021

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