Provider Demographics
NPI:1073383402
Name:JACKSON, CARMELLIA KAY (CSW, MFT-ASSOCIATE)
Entity Type:Individual
Prefix:
First Name:CARMELLIA
Middle Name:KAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CSW, MFT-ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TAMARACK DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-5431
Mailing Address - Country:US
Mailing Address - Phone:606-802-3779
Mailing Address - Fax:
Practice Address - Street 1:330 RACE ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-2156
Practice Address - Country:US
Practice Address - Phone:502-509-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY276506106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist