Provider Demographics
NPI:1124222955
Name:JACKSON, KIMBERLY HAMILTON (MA LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HAMILTON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WINDROCK WAY
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2258
Mailing Address - Country:US
Mailing Address - Phone:336-282-5142
Mailing Address - Fax:
Practice Address - Street 1:17 WINDROCK WAY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2258
Practice Address - Country:US
Practice Address - Phone:336-282-5142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2182101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional