Provider Demographics
NPI:1619552890
Name:JACKSON, KEVIA CONTRELLE (LPC)
Entity Type:Individual
Prefix:
First Name:KEVIA
Middle Name:CONTRELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 HERRINGTON RD APT 3303
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-6430
Mailing Address - Country:US
Mailing Address - Phone:404-895-5377
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
GALPC011309101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty