Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 129491 | KY |
Y | 103T00000X | Psychologist | 129491 | KY |
NPI | 1013932276 |
---|---|
Provider Name | Elizabeth Jackson |
First Address | Louisville, KY 40272-6808 |
Second Address | Louisville, KY 40202-1423 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2006 |
Last Update Date | 06/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P27978 | (02) | KY |