Provider Demographics
NPI:1104480615
Name:JACKSON, KIMBERLY NICOLE (LBA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27018 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7512
Mailing Address - Country:US
Mailing Address - Phone:276-525-4460
Mailing Address - Fax:
Practice Address - Street 1:27018 LEE HWY
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7512
Practice Address - Country:US
Practice Address - Phone:276-525-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001314103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst