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NPI Code Detail

MEDICARE: PATRICK DIOR JACKSON

MEDICARE: PATRICK DIOR JACKSON
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
1101YS0200XSchool Counselor201114318KY

General Provider Information

NPI Number : 1871141457
Entity Type Code : Individual
Provider Name (Legal Business Name) : PATRICK DIOR JACKSON
Provider Business Mailing Address
First Line : 811 STONEBENCH CIR
Second Line :
City : JEFFERSONVLLE
State : IN
Zip : 47130-4220
Country : US
Telephone Number : 812-557-5365
Fax Number :
Provider Business Practice Location Address
First Line : 5111 S 3RD ST
Second Line :
City : LOUISVILLE
State : KY
Zip : 40214-2601
Country : US
Telephone Number : 502-690-1511
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/28/2019
Last Update Date : 08/28/2019

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Directions to “ PATRICK DIOR JACKSON ” Practice Location

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