Individual
DR. JACKS X GILLES
Active
Sole proprietor
No
Provider details
NPI number
Gender
X
Credential
PSY.D., LP
Contact information
Practice address
633 BAXTER AVE, LOUISVILLE, KY 40204-1157
(502) 309-2408
Mailing address
633 BAXTER AVE, LOUISVILLE, KY 40204-1157
(502) 309-2403
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
129842
KY
103TC0700X
Clinical Psychologist
1745
KY
103TC0700X
Clinical Psychologist
2012-12
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
129842
LICENSE
KY
05
—
7100481420
—
KY
Enumeration date
09/04/2007
Last updated
11/19/2024
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