Provider Demographics
NPI:1467671982
Name:JACKSON, RICHARD CHAD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHAD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 BARGO ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2710
Mailing Address - Country:US
Mailing Address - Phone:606-878-7658
Mailing Address - Fax:
Practice Address - Street 1:1 TRILLIUM WAY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8426
Practice Address - Country:US
Practice Address - Phone:606-523-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC62048OtherCUMBERLAND HEALTHCARE INC
KYC62048OtherCUMBERLAND HEALTHCARE INC