Provider Demographics
NPI:1780918912
Name:JACKSON-LUZADER, KIMBERLY ANN (LPC, NCC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:JACKSON-LUZADER
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27602-0590
Mailing Address - Country:US
Mailing Address - Phone:919-996-1276
Mailing Address - Fax:
Practice Address - Street 1:6716 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6575
Practice Address - Country:US
Practice Address - Phone:919-996-1276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178006189101YP2500X
NC8795101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional