Provider Demographics
NPI:1750660106
Name:NSILULU, JACKSON LUFUAKIADI (PC, AND LICDC)
Entity Type:Individual
Prefix:MR
First Name:JACKSON
Middle Name:LUFUAKIADI
Last Name:NSILULU
Suffix:
Gender:M
Credentials:PC, AND LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 VERDON PLACE
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426
Mailing Address - Country:US
Mailing Address - Phone:937-286-3886
Mailing Address - Fax:
Practice Address - Street 1:313 VERDON PL
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-2754
Practice Address - Country:US
Practice Address - Phone:937-286-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0007453101Y00000X, 101YM0800X, 101YP2500X, 103K00000X
OH991504101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst