Basic Information
Provider Information
NPI: 1003295809
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JACKSON
FirstName: KATHERINE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 9920 W CAMELBACK RD UNIT 2026
Address2:  
City: PHOENIX
State: AZ
PostalCode: 850375056
CountryCode: US
TelephoneNumber: 2532080756
FaxNumber:  
Practice Location
Address1: 9920 W CAMELBACK RD UNIT 2026
Address2:  
City: PHOENIX
State: AZ
PostalCode: 850375056
CountryCode: US
TelephoneNumber: 2532080756
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/26/2015
LastUpdateDate: 01/13/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/13/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X  Y Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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