Individual
TIA KYLES JACKSON
Active
Individual
TIA KYLES JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
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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