Provider Demographics
NPI:1790233153
Name:JACKSON, KEZIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEZIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7711 BONHOMME AVE STE 720
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1908
Mailing Address - Country:US
Mailing Address - Phone:314-968-2350
Mailing Address - Fax:
Practice Address - Street 1:7711 BONHOMME AVE STE 720
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-1908
Practice Address - Country:US
Practice Address - Phone:314-968-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016035936103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist