Organization
MANDALA HOUSE, LLC
Active
Organization
MANDALA HOUSE, LLC
Active
Other names
Mandala House
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JACKS GILLES PSY.D., LP (EXECUTIVE DIRECTOR)
(502) 309-2403
Entity
Organization
Contact information
Practice address
633 BAXTER AVE, LOUISVILLE, KY 40204-1157
(502) 309-2408
(502) 771-4283
Mailing address
1169 EASTERN PKWY STE 3353, LOUISVILLE, KY 40217-1415
(502) 309-2403
(502) 771-4283
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
—
103TC0700X
Clinical Psychologist
Primary
—
—
103TC1900X
Counseling Psychologist
—
—
1041C0700X
Clinical Social Worker
—
—
106H00000X
Marriage & Family Therapist
—
—
2084P0800X
Psychiatry Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1659829760
NPI
KY
05
—
7100489150
—
KY
Enumeration date
09/18/2016
Last updated
06/05/2026
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