Provider Demographics
NPI:1124212972
Name:GILLES, JACKS X (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:JACKS
Middle Name:X
Last Name:GILLES
Suffix:
Gender:X
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1157
Mailing Address - Country:US
Mailing Address - Phone:502-309-2403
Mailing Address - Fax:
Practice Address - Street 1:633 BAXTER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1157
Practice Address - Country:US
Practice Address - Phone:502-309-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1745103TC0700X
KY2012-12103TC0700X
KY129842103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100481420Medicaid
KY129842OtherLICENSE