Basic Information
| Provider Information | |||||||||
| NPI: | 1003295809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | KATHERINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2942 N 24TH ST STE 114 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026413006 | ||||||||
| FaxNumber: | 6026413151 | ||||||||
| Practice Location | |||||||||
| Address1: | 9920 W CAMELBACK RD UNIT 2026 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850375056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532080756 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2015 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.