Provider Demographics
NPI:1649226549
Name:JACKSON, CALVIN (LPA)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CRANES ROOST CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3650
Mailing Address - Country:US
Mailing Address - Phone:270-765-2605
Mailing Address - Fax:270-766-1222
Practice Address - Street 1:1311 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2621
Practice Address - Country:US
Practice Address - Phone:270-769-1304
Practice Address - Fax:270-234-8028
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0274101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000338946OtherANTHEM
KS30605018Medicaid