Provider Demographics
NPI:1336213784
Name:JACKSON BEHAVIORAL HEALTH PROFESSIONALS, PLLC
Entity Type:Organization
Organization Name:JACKSON BEHAVIORAL HEALTH PROFESSIONALS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MATT
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:606-526-9500
Mailing Address - Street 1:PO BOX 2343
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-2343
Mailing Address - Country:US
Mailing Address - Phone:606-526-9500
Mailing Address - Fax:606-526-8080
Practice Address - Street 1:1013 MASTER ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1065
Practice Address - Country:US
Practice Address - Phone:606-526-9500
Practice Address - Fax:606-526-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0480101YA0400X
KYKY16251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty