Provider Demographics
NPI:1487210399
Name:JACKSON, ANTHONY N (CADC)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC
Mailing Address - Street 1:6445 EAST HAVEN WAY
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122
Mailing Address - Country:US
Mailing Address - Phone:270-996-8612
Mailing Address - Fax:
Practice Address - Street 1:6445 EAST HAVEN WAY
Practice Address - Street 2:
Practice Address - City:ALVATON
Practice Address - State:KY
Practice Address - Zip Code:42122
Practice Address - Country:US
Practice Address - Phone:502-509-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY280600101YP2500X
KY280595101YA0400X
KY266965101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional