Provider Demographics
NPI:1235463308
Name:JACKSON KELLY, JAMILLAH A (MS/EDS, NCC, LCMHCS)
Entity type:Individual
Prefix:MRS
First Name:JAMILLAH
Middle Name:A
Last Name:JACKSON KELLY
Suffix:
Gender:F
Credentials:MS/EDS, NCC, LCMHCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 PEACH HILL LN
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-5428
Mailing Address - Country:US
Mailing Address - Phone:336-327-7361
Mailing Address - Fax:
Practice Address - Street 1:4600 EMPEROR BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-8577
Practice Address - Country:US
Practice Address - Phone:919-651-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8340101Y00000X, 101YM0800X, 101YP2500X
101YA0400X, 374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
246803OtherNATIONAL BOARD FOR CERTIFIED COUNSELORS, INC.
NCS8340OtherTHE NC BOARD OF LICENSED CLINICAL MENTAL HEALTH COUNSELORS
511277OtherNATIONAL CERTIFICATION COMMISSION FOR ADDICTION PROFESSIONALS
NC8340OtherTHE NC BOARD OF LICENSED PROFESSIONAL COUNSELORS