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NPI Code Detail

MEDICARE: KAMI JACKSON LPC

MEDICARE: KAMI JACKSON LPC
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
1101YP2500XProfessional Counselor70594TX
2101YP2500XProfessional Counselor70593TX

General Provider Information

NPI Number : 1790249860
Entity Type Code : Individual
Provider Name (Legal Business Name) : KAMI JACKSON LPC
Provider Business Mailing Address
First Line : 7925 S BROADWAY AVE STE 820
Second Line :
City : TYLER
State : TX
Zip : 75703-5255
Country : US
Telephone Number : 903-330-0800
Fax Number :
Provider Business Practice Location Address
First Line : 7925 S BROADWAY AVE STE 820
Second Line :
City : TYLER
State : TX
Zip : 75703-5255
Country : US
Telephone Number : 903-330-0800
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/23/2019
Last Update Date : 01/23/2019

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Directions to “ KAMI JACKSON LPC” Practice Location

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