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
633 BAXTER AVE, LOUISVILLE, KY 40204-1157
(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
09/30/2024
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