Jacks X Gilles, PSY.D., LP

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

129842 Issued in KY

Practice address

633 Baxter Ave
Louisville, KY 40204-1157

Phone

(502) 309-2408

NPI assigned

Sep 4, 2007

Sex

Unspecified or another gender identity

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in KY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Psychologist

Education

Other, 2011

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Mandala House, LLCGroup PAC ID 4789957135, 8 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mandala House, LLC

  • Clinical Psychologist
  • Louisville, KY
  • NPI 1659829760
  Medicare reassignment Care Compare group NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1188864000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1731974400000",
    "number": "1124212972",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "633 BAXTER AVE",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402041157",
            "telephone_number": "502-309-2403"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "633 BAXTER AVE",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402041157",
            "telephone_number": "502-309-2408"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1190 E Broadway",
            "address_purpose": "LOCATION",
            "city": "Louisville",
            "state": "KY",
            "postal_code": "402041712",
            "country_code": "US",
            "telephone_number": "502-627-0905",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "GILLES",
        "first_name": "JACKS",
        "middle_name": "X",
        "name_prefix": "Dr.",
        "credential": "PSY.D., LP",
        "sole_proprietor": "NO",
        "sex": "X",
        "enumeration_date": "2007-09-04",
        "last_updated": "2024-11-19",
        "certification_date": "2024-11-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "KY",
            "license": "1745",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "KY",
            "license": "2012-12",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "KY",
            "license": "129842",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100481420",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "129842",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Ravi Gill, MD
• Tara Gill
• Tia Gill
• Morgan Elizabeth Gillenwater
• Christina Gormastic Gilles, DPT
• Christian N Gillespie, LCSW
• Michelle Lea Gillespie, ARNP
• Robin Denise Gillespie, RD, LD
• Siobhan Gillespie
• Amy Gilley, PT

• Clinical Psychologist in Louisville, KY
• Providers in Louisville, KY by specialty
• Clinical Psychologist in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.