Provider Demographics
NPI:1386216703
Name:JACKSON, KYLER
Entity Type:Individual
Prefix:
First Name:KYLER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 GLENSPRINGS DR STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-2353
Mailing Address - Country:US
Mailing Address - Phone:513-771-9600
Mailing Address - Fax:
Practice Address - Street 1:4788 WASHTENAW AVE APT B7
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3113
Practice Address - Country:US
Practice Address - Phone:717-808-7198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2101858-TRNE104100000X
MI6851114487104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker