Provider Demographics
NPI:1487023032
Name:JACKSON, KELLY I
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:I
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD
Mailing Address - Street 2:SAMARITAN BEHAVIORAL HEALTH INC, 4TH FLOOR NW BLDG
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:937-276-8269
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:SAMARITAN BEHAVIORAL HEALTH INC, 1ST FLOOR NW BLDG
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator