Provider Demographics
NPI:1689966731
Name:JENKINS, KACEY LUSK (PHD, LMFTA)
Entity Type:Individual
Prefix:MRS
First Name:KACEY
Middle Name:LUSK
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PHD, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 ASHLEY CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5801
Mailing Address - Country:US
Mailing Address - Phone:270-935-5125
Mailing Address - Fax:270-846-4887
Practice Address - Street 1:1711 ASHLEY CIR
Practice Address - Street 2:SUITE 2
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5801
Practice Address - Country:US
Practice Address - Phone:270-935-5125
Practice Address - Fax:270-846-4887
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KYMFTMFT00218369106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health