Provider Demographics
NPI:1821247388
Name:JACKSON, KYLE B
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 RIVERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-3104
Mailing Address - Country:US
Mailing Address - Phone:541-513-7634
Mailing Address - Fax:
Practice Address - Street 1:1759 RIVERVIEW ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-3104
Practice Address - Country:US
Practice Address - Phone:541-513-7634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health