Provider Demographics
NPI:1851020150
Name:JACKSON, KELSEA ARTESSE
Entity type:Individual
Prefix:
First Name:KELSEA
Middle Name:ARTESSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 LEAFMORE RD SW APT 2
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-3858
Mailing Address - Country:US
Mailing Address - Phone:404-914-8534
Mailing Address - Fax:
Practice Address - Street 1:342 LEAFMORE RD SW APT 2
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-3858
Practice Address - Country:US
Practice Address - Phone:404-914-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-179717106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician