Provider Demographics
NPI:1265296362
Name:JACKSON, KYLE (PHD PSYCHOLOGY)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2992 N MILLER RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6963
Mailing Address - Country:US
Mailing Address - Phone:602-767-3233
Mailing Address - Fax:
Practice Address - Street 1:2992 N MILLER RD UNIT 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6963
Practice Address - Country:US
Practice Address - Phone:602-767-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-005667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist