Provider Demographics
NPI:1003955162
Name:JACKSON, KIMBERLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 KAREN AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-3017
Mailing Address - Country:US
Mailing Address - Phone:512-458-5866
Mailing Address - Fax:
Practice Address - Street 1:1106 CLAYTON LN
Practice Address - Street 2:SUITE 212E
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-1066
Practice Address - Country:US
Practice Address - Phone:512-659-3023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical