Individual
TIA KYLES JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
1444 E SHELBY DR STE 424, MEMPHIS, TN 38116-7260
(901) 270-8522
Mailing address
747 CRESCENT AVE, MEMPHIS, TN 38116-6209
(901) 270-8522
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
1861M
AR
1041C0700X
Clinical Social Worker
4461-C
AR
1041C0700X
Clinical Social Worker
Primary
6588
TN
1041C0700X
Clinical Social Worker
C9077
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
169031795
—
AR
Enumeration date
08/21/2012
Last updated
10/18/2018
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