Provider Demographics
NPI:1619412228
Name:JACKSON, KATHERINE THOMPSON (MDIV)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:THOMPSON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 JEFFERSON PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0001
Mailing Address - Country:US
Mailing Address - Phone:434-924-2642
Mailing Address - Fax:434-924-1139
Practice Address - Street 1:1221 JEFFERSON PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-924-2642
Practice Address - Fax:434-924-1139
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YP1600X
282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access