Active NPI
Kimberly Jackson
- Counselor
- Tallulah, LA
National Provider Identifier
1962858050
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Counselor
- License
- 10088
- Practice address
- 1705 Felicia Ave
Tallulah, LA 71282 - Phone
- (318) 574-1232
- NPI assigned
- May 9, 2016
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Case Manager/Care Coordinator | 171M00000X | LA | ||
| Counselor | 101Y00000X | 10088 | LA | Primary |
| Mental Health Counselor | 101YM0800X | 10088 | LA |
Addresses
Primary practice location
1705 Felicia Ave
Tallulah, LA 71282
Mailing address
1705 Felicia Ave
Tallulah, LA 71282-8203
Phone (318) 574-1232
Other practice location 1
1700 Lake St
Lake Providence, LA 71254-5208
Phone (318) 559-0414
Other names 1
- Kimberly Jackson
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 10088 | LA | MD | Counselor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Cognitive Development Center, LLC | Past | Accepting new patients |
Organizations & group practices 1
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.
-
- Mental Health Clinic/Center (Including Community Mental Health Center)
- Tallulah, LA
- NPI 1538236328
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1462752000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1761696000000",
"number": "1962858050",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1705 FELICIA AVE",
"city": "TALLULAH",
"state": "LA",
"postal_code": "712828203",
"telephone_number": "318-574-1232"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1705 FELICIA AVE",
"city": "TALLULAH",
"state": "LA",
"postal_code": "71282",
"telephone_number": "318-574-1232"
}
],
"practiceLocations": [
{
"address_1": "1700 Lake St",
"address_purpose": "LOCATION",
"city": "Lake Providence",
"state": "LA",
"postal_code": "712545208",
"country_code": "US",
"telephone_number": "318-559-0414",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "JACKSON",
"first_name": "KIMBERLY",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2016-05-09",
"last_updated": "2025-10-29",
"certification_date": "2025-10-29",
"status": "A"
},
"taxonomies": [
{
"code": "171M00000X",
"taxonomy_group": "",
"desc": "Case Manager/Care Coordinator",
"state": "LA",
"license": null,
"primary": false
},
{
"code": "101Y00000X",
"taxonomy_group": "",
"desc": "Counselor",
"state": "LA",
"license": "10088",
"primary": true
},
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "LA",
"license": "10088",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "KIMBERLY",
"last_name": "JACKSON",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Tallulah, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.