Provider Demographics
NPI:1871466722
Name:JACKSON, KATHLEEN MAEVE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MAEVE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 QUAKER MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-6163
Mailing Address - Country:US
Mailing Address - Phone:919-356-1687
Mailing Address - Fax:
Practice Address - Street 1:8319 SIX FORKS RD STE 203
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2108
Practice Address - Country:US
Practice Address - Phone:919-307-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0222951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical