Provider Demographics
NPI:1679352017
Name:JACKSON, KIMBERLY L (LSW, MSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW, MSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:L
Other - Last Name:JACKSON -GAYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW, MSW
Mailing Address - Street 1:2776 PARKWAY CV
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4656
Mailing Address - Country:US
Mailing Address - Phone:419-699-2288
Mailing Address - Fax:
Practice Address - Street 1:2776 PARKWAY CV
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4656
Practice Address - Country:US
Practice Address - Phone:419-699-2288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1100848104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty