Provider Demographics
NPI:1669930517
Name:JACKSON, ALLISON CHAREE (LPCC)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:CHAREE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1719
Mailing Address - Country:US
Mailing Address - Phone:606-834-0020
Mailing Address - Fax:606-834-0049
Practice Address - Street 1:1448 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1719
Practice Address - Country:US
Practice Address - Phone:606-834-0020
Practice Address - Fax:606-834-0049
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104618101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100587020Medicaid