Provider Demographics
NPI:1821316159
Name:JACKSON, KIMBERLY DAWN (LPC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:10901 E WINNER RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64052-3755
Mailing Address - Country:US
Mailing Address - Phone:816-254-3652
Mailing Address - Fax:816-254-9243
Practice Address - Street 1:10901 E WINNER RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64052-3755
Practice Address - Country:US
Practice Address - Phone:816-254-3652
Practice Address - Fax:816-254-9243
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009036113101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional