Provider Demographics
NPI:1902229982
Name:JACKSON, SAMEERA CHOWDHURY (LPCA)
Entity Type:Individual
Prefix:
First Name:SAMEERA
Middle Name:CHOWDHURY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 MIMOSA VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-5834
Mailing Address - Country:US
Mailing Address - Phone:502-644-5232
Mailing Address - Fax:502-966-8252
Practice Address - Street 1:4010 DUPONT CIR
Practice Address - Street 2:SUITE 582
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4812
Practice Address - Country:US
Practice Address - Phone:502-899-5411
Practice Address - Fax:502-899-5411
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0732101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional