Provider Demographics
NPI:1871141457
Name:JACKSON, PATRICK DIOR
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:DIOR
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 STONEBENCH CIR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVLLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-4220
Mailing Address - Country:US
Mailing Address - Phone:812-557-5365
Mailing Address - Fax:
Practice Address - Street 1:5111 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-2601
Practice Address - Country:US
Practice Address - Phone:502-690-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201114318101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool