Provider Demographics
NPI:1427548296
Name:JACKSON, FRANK VASS III (TEMPORARY CADC)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:VASS
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:TEMPORARY CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-3986
Mailing Address - Country:US
Mailing Address - Phone:270-781-3387
Mailing Address - Fax:
Practice Address - Street 1:2349 RUSSELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3986
Practice Address - Country:US
Practice Address - Phone:270-438-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY172452101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)