Provider Demographics
NPI:1205727336
Name:JACKSON, KIMBERLY R (LISW-CP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 BARNWELL RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3915
Mailing Address - Country:US
Mailing Address - Phone:864-256-7649
Mailing Address - Fax:
Practice Address - Street 1:552 BARNWELL RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3915
Practice Address - Country:US
Practice Address - Phone:864-256-7649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC175681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical