Provider Demographics
NPI:1265144000
Name:JACKSON, KATHERINE (MA, LMFTA)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10204 RIVER BANK DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8928
Mailing Address - Country:US
Mailing Address - Phone:919-332-1517
Mailing Address - Fax:
Practice Address - Street 1:6604 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6521
Practice Address - Country:US
Practice Address - Phone:919-725-8086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12495A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12495AOtherLICENSE NUMBER