MEDICARE: KAYLA JACKSON LCSW

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	1041C0700X	Clinical Social Worker	09927552	CO

General Provider Information

NPI Number	:	1659013753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA JACKSON LCSW

Provider Business Mailing Address
First Line	:	1250 S BUCKLEY RD
Second Line	:	STE 1 #161
City	:	AURORA
State	:	CO
Zip	:	80017
Country	:	US
Telephone Number	:	720-509-9277
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 SOUTH BUCKLEY ROAD
Second Line	:	STE 1 #161
City	:	AURORA
State	:	CO
Zip	:	80017-8001
Country	:	US
Telephone Number	:	720-509-9277
Fax Number	:

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

Provider Enumeration Date	:	04/08/2022
Last Update Date	:	06/21/2022

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