Provider Demographics
NPI:1871082438
Name:JACKSON, KYLIAH LANEICE (LISW-CP)
Entity type:Individual
Prefix:
First Name:KYLIAH
Middle Name:LANEICE
Last Name:JACKSON
Suffix:
Gender:
Credentials:LISW-CP
Other - Prefix:
Other - First Name:KYLIAH
Other - Middle Name:LANEICE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:1 RICE POINTE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9025
Mailing Address - Country:US
Mailing Address - Phone:708-675-9061
Mailing Address - Fax:
Practice Address - Street 1:1 RICE POINTE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9025
Practice Address - Country:US
Practice Address - Phone:708-675-9061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2025-02-24
Deactivation Date:2024-12-09
Deactivation Code:
Reactivation Date:2024-12-19
Provider Licenses
StateLicense IDTaxonomies
MN294031041C0700X, 101YM0800X
SC17505101YM0800X, 1041C0700X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician