Provider Demographics
NPI:1578886156
Name:JACKSON, KATHLEEN KNOUS
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:KNOUS
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 1:2111 CHAMPA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2529
Mailing Address - Country:US
Mailing Address - Phone:303-297-4058
Mailing Address - Fax:303-340-3934
Practice Address - Street 1:2111 CHAMPA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2529
Practice Address - Country:US
Practice Address - Phone:303-297-4058
Practice Address - Fax:303-340-3934
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC10770171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator