Provider Demographics
NPI:1144668807
Name:JACKSON, KATELAN (LMHC)
Entity type:Individual
Prefix:
First Name:KATELAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KATELAN
Other - Middle Name:
Other - Last Name:SONGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 PIN OAK DR
Mailing Address - Street 2:
Mailing Address - City:EAST SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02537-1313
Mailing Address - Country:US
Mailing Address - Phone:508-348-9588
Mailing Address - Fax:
Practice Address - Street 1:68 TUPPER RD UNIT 10
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:MA
Practice Address - Zip Code:02563-1872
Practice Address - Country:US
Practice Address - Phone:508-348-9588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
MA10578101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool