Provider Demographics
NPI:1902220569
Name:JACKSON, JASMINE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
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 1:901 US HIGHWAY 68 STE 900
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9190
Mailing Address - Country:US
Mailing Address - Phone:606-375-2127
Mailing Address - Fax:
Practice Address - Street 1:901 US HIGHWAY 68 STE 900
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9190
Practice Address - Country:US
Practice Address - Phone:606-584-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional