Provider Demographics
NPI:1003378241
Name:JACKSON, KASEY B (LCSW-S)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW-S
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:LYNN
Other - Last Name:BOURBON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1221 W BEN WHITE BLVD STE 210A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7182
Mailing Address - Country:US
Mailing Address - Phone:512-960-4553
Mailing Address - Fax:512-887-3970
Practice Address - Street 1:12120 MANCHACA RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-2710
Practice Address - Country:US
Practice Address - Phone:512-960-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX521501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical