Provider Demographics
NPI:1891135364
Name:JACKSON, KATRINA NICOLE
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-5084
Mailing Address - Country:US
Mailing Address - Phone:843-601-4558
Mailing Address - Fax:
Practice Address - Street 1:524 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-5084
Practice Address - Country:US
Practice Address - Phone:843-601-4558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst