Provider Demographics
NPI:1780420778
Name:KRESSE, KYLE JACKSON (LAC)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JACKSON
Last Name:KRESSE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 12TH PL STE 13
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1433
Mailing Address - Country:US
Mailing Address - Phone:844-762-3748
Mailing Address - Fax:
Practice Address - Street 1:919 12TH PL STE 13
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1433
Practice Address - Country:US
Practice Address - Phone:844-762-3748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22785101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor