Provider Demographics
NPI:1538459227
Name:JACKSON, KIMBERLY DIONE (MS,LPC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DIONE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS,LPC
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:DIONE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:233 MITCHELL ST SW STE 510
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3322
Mailing Address - Country:US
Mailing Address - Phone:678-595-8060
Mailing Address - Fax:678-595-8060
Practice Address - Street 1:233 MITCHELL ST SW STE 510
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3322
Practice Address - Country:US
Practice Address - Phone:678-595-8060
Practice Address - Fax:678-595-8060
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006188101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional