Provider Demographics
NPI:1417165655
Name:THOMAS, JACKY T (LCSW)
Entity Type:Individual
Prefix:
First Name:JACKY
Middle Name:T
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 NICHOLASVILLE RD STE 400
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1429
Mailing Address - Country:US
Mailing Address - Phone:859-276-5285
Mailing Address - Fax:859-277-3513
Practice Address - Street 1:1517 NICHOLASVILLE RD STE 400
Practice Address - Street 2:SUITE 400
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1429
Practice Address - Country:US
Practice Address - Phone:859-276-5285
Practice Address - Fax:859-277-3513
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000051966OtherANTHEM
KY000000051966OtherANTHEM