Individual
KELLY JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
11631 CEDAR ST, CEDAR LAKE, IN 46303-7290
(219) 682-8211
Mailing address
11631 CEDAR STREET, CEDAR LAKE, IN 46303, EAST CEDAR LAKE, IN 46303
(219) 682-8211
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
34006136A
IN
Other
Enumeration date
08/19/2021
Last updated
08/19/2021
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