Provider Demographics
NPI:1538417639
Name:KYLES JACKSON, TIA (LCSW)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:KYLES JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:TIA
Other - Middle Name:
Other - Last Name:KYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:747 CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6209
Mailing Address - Country:US
Mailing Address - Phone:901-270-8522
Mailing Address - Fax:
Practice Address - Street 1:1444 E SHELBY DR STE 424
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-7260
Practice Address - Country:US
Practice Address - Phone:901-270-8522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1861M104100000X
AR4461-C1041C0700X
MSC90771041C0700X
TN65881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169031795Medicaid